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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:03:46 AM


Document Has Been Signed on 10/27/2022 11:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:MONTCLAIR ROYALE SENIOR LIVINGFACILITY NUMBER:
361800147
ADMINISTRATOR:SANTOS, ANNAMARIEFACILITY TYPE:
740
ADDRESS:9685 MONTE VISTA AVETELEPHONE:
(909) 621-3545
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:236CENSUS: 130DATE:
10/27/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Annamarie Santos-TabilaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Melody Brown and Victoria Chitgian met with Administrator Annamarie Santos-Tabila at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 10/27/2022 at 10:30 AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

During the facility visit last 07/15/2022 at 11:30 AM, LPA Brown reviewed documents and observed that Staff Six (S6) have a current criminal background clearance but S6 is not currently associated to the facility. Staff interviews and records review of Personnel Report (LIC500) and Employee Roster indicated S6 started working at the facility 06/02/2022.

Civil Penalty was assessed with the amount of $500.00 during the Office Visit for failure to transfer S6 Criminal Background Clearance to the facility.

In addition, LPA Brown reviewed facility's incident reports and LPA Brown did not find any Special Incident Reports (SIRs) that the facility submitted to Community Care Licensing Division (CCLD) to report R1's hospitalization and LPA Brown will issue a citation for not reporting the incident at the facility as this pose potential risk to residents in care.

An exit interview was conducted where this report (LIC809), LIC80D, LIC421BG and Appeal Rights were discussed and provided to Administrator Annamarie Santos-Tabila .

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2022 11:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing...(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:
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Based on interview and records review, the Licensee did not comply with the section cited above by not transferring Staff 6 (S6) Criminal Background Clearance to the facility. This poses a potential Health and Safety risk to the resident in care.
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Type B
11/03/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by:
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Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) of R1's hospitalization CCLD ASC. This poses a potential Health and Safety risk to the resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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