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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:02:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20230526084728
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: 101DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff not providing meals as suggested by doctor.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto to discuss the complaint and allegations.

The investigation consisted of staff and resident interviews, record reviews and observations of the kitchen and food service. During staff interviews, LPA learned that dietary needs are discussed during the admissions process. Their dietary needs are also documented. If the dietary needs should change, the doctor sends orders directly to the facility. Doctor orders for dietary needs are given to the Dietary Staff who keeps records of these changes. Kitchen staff print a daily list of residents who require a certain diet. Kitchen staff report that meals are always prepared and provided to residents in care. Often times, resident may not like one item or another. It is a resident's choice to eat the food or not eat the food. During resident interviews, LPA learned that the resident is being provided food items as suggested by the doctor. The food may not be prepared to all residents' liking's. LPA observed no evidence that meals are not being provided based on doctors orders.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 2
Control Number 56-AS-20230526084728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 05/30/2023
NARRATIVE
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We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2