361800147-12-7-2022-56-AS-NBRN-CMBPMU-20221221102654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:59:54 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2022 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220602102400

FACILITY NAME:	MONTCLAIR ROYALE SENIOR LIVING		FACILITY NUMBER:	361800147
ADMINISTRATOR:	SANTOS, ANNAMARIE		FACILITY TYPE:	740
ADDRESS:	9685 MONTE VISTA AVE		TELEPHONE:	(909) 621-3545
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	236	CENSUS: 129	DATE:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Araceli Soto		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents elope due to facility door lock broken.
Food service staff serve expired food and uncooked food.
Facility is in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to continue the investigation of and deliver findings on the above mentioned allegations. LPA met with care coordinator Araceli Soto who was informed of the reason for today's visit. The investigation consisted of file review, interviews with relevant parties, and observations of the facility.

Allegation 1 and 2: Residents elope due to facility door lock broken AND Facility is in disrepair. The Department received a special incident report of resident elopement. Staff interview revealed that the memory care door lock was broken, allowing memory care residents to leave the unit. Staff further stated that care staff assigned to temporarily guard the door quit and walked off in the middle of their shift. This allegation is substantiated.

Allegation 3: Food service staff serve expired food and uncooked food. Witness interviews confirmed that food items were expired and tossed out. Interviews reveal that staff are unable to verify whether food items have been cooked thoroughly. This allegation is substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2022 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220602102400

FACILITY NAME:	MONTCLAIR ROYALE SENIOR LIVING		FACILITY NUMBER:	361800147
ADMINISTRATOR:	SANTOS, ANNAMARIE		FACILITY TYPE:	740
ADDRESS:	9685 MONTE VISTA AVE		TELEPHONE:	(909) 621-3545
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	236	CENSUS:	DATE:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Araceli Soto		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handle residents roughly.
Residents bathroom plumbing is in disrepair.
Staff did not administer medication as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to continue the investigation of and deliver findings on the above mentioned allegations. LPA met with care coordinator Araceli Soto who was informed of the reason for today's visit. The investigation consisted of file review, interviews with relevant parties, and observations of the facility.

Allegation 1: Staff handle residents roughly. It is alleged that staff 1 and staff 2 have been rough with residents. Resident interviews reveal that staff have not been rough with them and are friendly and nice when they provide assistance.

Allegation 2: Residents bathroom plumbing is in disrepair. LPA received maintenance logs showing bathroom fixtures breaking and being fixed. Resident interview verified that the facility repaired their request the same day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 56-AS-20220602102400

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/07/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation 3: Staff did not administer medication as prescribed. Staff interviews confirmed that medication is administered during usual meal times. Staff further state that medication is popped from their bubble pack before medication is given to the resident.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 56-AS-20220602102400

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/07/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation 3: Facility is in disrepair. On 4/7/22, LPA Bueno observed the facility front double doors with a broken left door and observed maintenance staff repair the door. LPA observed the same facility door permanently secured with a sign posted to "use other door", the right one, during a subsequent visit on 5/6/22. During today's visit, LPA Bueno reviewed documents showing that the memory care unit lock was broken as of 5/17/22 and was repaired on 6/11/22 by the same company providing security services for the memory care unit.

Based on interviews and records review, the above allegations are therefore SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. These pose health and safety risks to residents in care. Refer to LIC 9099D for deficiency cited.

An exit interview was conducted with Mrs. Soto and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 56-AS-20220602102400

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/09/2022 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	As of today's visit, the facility has repaired the memory care unit and facility front doors. The facility shall submit proof of recent service for roof maintenance to the Department no later than the POC date
	8 9 10 11 12 13 14	LPA observed a broken front door and LPA received a recorded video of the facility common room ceiling leaking heavily. This poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 12/30/2022 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.	1 2 3 4 5 6 7	As of today's visit, the facility had a change in kitchen management and proper food handling practices are currently in place. CCL shall receive an end of year progress report from head chef on newly implemented procedures for all kitchen staff by the POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Witness interviews confirm that expired food items and milk were stored and sometimes served to residents in care. This poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5