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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 12/07/2022
Date Signed: 12/07/2022 05:02:55 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
03/29/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220329095154
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: 129DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Araceli SotoTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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9
Uncleared staff working at the facility.
Staff have not received required training.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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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: Uncleared staff working at the facility. LPA reviewed records and found Staff (S1) was associated to the facility for a time. Interview with staff confirms that S1 was employed by this facility and terminated when the facility received the exemption denial letter from CBMP.

Allegation 2: Staff have not received required training. LPA received and reviewed facility med tech schedule and found Staff (S2) on rotation. Staff interview revealed that S2 has not received their full medication training and is shadowing current med techs. Records show that S2 is assigned a schedule and witness interview verified that S2 has been administering resident medication.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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 7
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
03/29/2022 and conducted by Evaluator Anna Bueno
COMPLAINT CONTROL NUMBER: 56-AS-20220329095154

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: 129DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Araceli SotoTIME COMPLETED:
05:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not follow residents' physician's orders.
Facility has a scabies breakout.
Facility not maintained clean and sanitary.
Facility does not meet residents' personal care needs.
Staff do not groom residents.
Staff do not shower residents.
INVESTIGATION FINDINGS:
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5
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7
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9
10
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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 do not follow residents' physician's orders. Witness interviews reveal that staff, specifically medication technicians, are not following physician's orders for medication administration. LPA reviewed a sample of medications from three medication carts and found stickers on medications as: AM/Morning, Noon, PM/Evening, Bedtime, and As Needed. Interview with lead med tech revealed that there is no specific time of day that medications must be given however the facility administers medications around meal and bed times for consistency. This allegation is unsubstantiated.

Allegation 2: Facility has a scabies breakout. LPA received and reviewed records showing that residents R1 and R2 had dermatitis and are prescribed cream for relief. This allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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 7
Control Number 56-AS-20220329095154
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
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Allegation 3: Facility not maintained clean and sanitary. LPA received and reviewed records for scheduled carpet cleaning by a third-party vendor. LPA toured the facility, including the memory care unit with newer carpet than the rest of the facility, and observed the facility as orderly. Staff interviews reveal that some residents may create more mess than other while some may purposely leave clutter and trash around the facility. This allegation is unsubstantiated.

Allegation 4, 5, and 6: Facility does not meet residents' personal care needs, Staff do not groom residents, and Staff do not shower residents. LPA received and reviewed resident schedule for laundry and showers. Also, LPA toured the facility, including the memory care unit, and observed residents R1 and R2 in the memory care hallway with appropriate clothing and shoes. Interview with staff reveal that it is not unusual for memory care residents to share or forget clothing items. LPA observed a storage closet in the memory care common area with lost items and observed these items with names. These allegations are therefore unsubstantiated.

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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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 7
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
03/29/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220329095154

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: 129DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Araceli SotoTIME COMPLETED:
05:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not assist residents with their self administered medications.
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.

The allegation is that staff do not assist residents with their self administered medications. The investigation revealed that residents are given their medication and, if the resident refuses the medication, then staff will respect the resident’s decision and notify the care coordinator. California Code of Regulations section 87465 state that assistance for self administered medication is as needed, with limitations, and specific regulations for prescription and non-prescription PRN (as needed) medications

Based on the available information, this complaint allegation is UNFOUNDED. A finding of unfounded means that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed, and a copy was provided to facility representative at the conclusion of the visit.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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: 4 of 7
Control Number 56-AS-20220329095154
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 A
11/28/2022
Section Cited
CCR
87355(e)(1)
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(e) All individuals subject to a criminal record review pursuant to HSC Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a CA clearance or a criminal record exemption as required by the Department...
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At the time of the initial visit, S1 had been separated from the facility.
During today's visit, it was found that Staff1 is currently working while their clearance is still pending.
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This requirement was not met as evidenced by:
Records review and staff interview confirm that S1 was working prior to receiving their background clearance. This poses an immediate safety and personal rights risk to residents in care.
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HSC
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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: 6 of 7
Control Number 56-AS-20220329095154
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)
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3
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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:
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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.
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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.
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Type B
12/09/2022
Section Cited
CCR
87411(c)(3)(D)
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Policies and procedures regarding medications, including knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection.
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As of today's visit, the facility has implemented a documented two full week training for all staff administering medication. As of today's visit, S2 is no longer associated to the facility.
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This requirement was not met as evidenced by:
Staff interview revealed that S2 has not completed their initial medication training and the facility is unable to provide proof that S2 had received such training. This poses an immediate health and safety risk to residents in care.
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9
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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 7
Control Number 56-AS-20220329095154
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
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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. Also, LPA Bueno received video recording of a leaky ceiling in a facility common room.

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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 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: 7 of 7