<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 03/22/2023
Date Signed: 03/22/2023 10:31:43 AM


Document Has Been Signed on 03/22/2023 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gwen Galvan, Asst. Care CoordinatorTIME COMPLETED:
10:45 AM
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
Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to conduct a case management visit for health and safety. Specifically, following up regarding a theft and loss incident involving a resident. LPA introduced self and stated purpose of the visit. LPA met with Assistant Care Coordinator Gwen Galvan, (ACC). LPA inquired about the timeline of events on 3/13/23. ACC reported that on 3/13/23 the resident was taken to the San Antonio ER due to chronic foot pain. During the time the EMT's were preparing the resident for departure. EMT's commented, ".....That the resident's room is too cluttered making the room inaccessible to staff or medical professionals to get in and assist the resident. There was no place to put the resident to be able to access him." After the resident left staff entered the resident's room to clean it up.
LPA's visit consisted of staff interview, collection and review of resident file. The incident report submitted on 3/13/23.

ACC also reported that items removed from the resident's room were what the facility considers contraband. Illegal substances, open torch lighter, switchblade and powered drill were removed from the room. Also, trash items. Otherwise the room was made orderly. Items were put back in their place. Items in drawers, clothes in dresser, bathroom counter cleared. Upon the resident's return he discovered that his room had been cleaned and items removed. The resident became irate and showing aggressive behaviors. Kicking and yelling at staff, banging on the doors and glass window at the front desk. Police were contacted to make a visit due to the resident's aggressive behavior. When Police arrived, staff reported the incident and reviewed items taken from the room. The Police did not confiscate the items, they remained with the staff for storage. The resident's kicking of the facility property, resulted in a wound reopening and he was taken to the ER for medical attention.
LPA was provided a Police Report No., copy of the resident's personal property list and before and after photos of the resident's room being cleaned.

No deficiencies were observed during this visit. An exit interview was conducted where this report was discussed and provided to Assistant Care Coordinator,
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1