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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:54:43 PM


Document Has Been Signed on 06/28/2023 01:54 PM - 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: 127DATE:
06/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:AnnaMarie Santos-Tabila, Admin., & Araceli Soto, Care Coord.TIME COMPLETED:
12:40 PM
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 unannounced to conduct a case management visit. This case management visit was conducted to collect additional information regarding complaint #56-AS-20230413141951 and obtain signatures
.
LPA introduced self to staff and stated purpose of the visit. LPA met with Administrator, AnnaMarie Santos-Tabila and Care Coordinator, Araceli Soto. This visit included an interviews, collection and review of additional records and a walk through the residents room.

No deficiencies were observed during this visit. An exit interview was conducted, this report was reviewed, discussed and provided to Facility Representatives.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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