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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 01/10/2023
Date Signed: 01/10/2023 10:31:47 AM


Document Has Been Signed on 01/10/2023 10:31 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: 127DATE:
01/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Annamarie SantosTIME COMPLETED:
10:33 AM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced subsequent visit to this facility to conduct additional interviews for complaint control number 56-AS-20220329095154 and to discuss the requested extension for a plan of correction (POC). LPA met with administrator Annamarie Santos who was informed of the nature of today's visit.

LPA interviewed four residents and one staff. LPA approved a new POC date of 2/9/23 for citation issued during 12/7/22 visit [CCR 87555(b)(8)].

No deficiencies were cited during today’s visit. An exit interview was conducted where this report was discussed with, and a copy was provided to Mrs. Santos at the conclusion of the visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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