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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:29:21 PM


Document Has Been Signed on 07/18/2023 02:29 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: 126DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) conducted an unannounced complaint visit for complaint number - 56-AS-20230717143120. During this visit, LPA observed deficiencies not related to the complaint allegations.

At 11:30am, while in resident's room, LPA observed the resident room windows to be missing window shades on both the sliding window and the window adjacent to it. At approximately 11:33am, LPA observed the resident closets to be missing both sliding doors. After observing the closet, at approximately 11:35am, LPA observed three dark stains on the carpet near the foot of the resident bed. LPA entered the resident restroom. Along the wall opposite the sinks, LPA observed the towel racks missing from the wall; appearing broken off the wall. Resident interviews reveal the windows were missing shades, the broken towel rack and stained carpet were in that condition upon moving in February 2023.

During staff interviews, LPA learned that there are no records indicating residents reported any maintenance issues in the residents' room. Staff deny having any knowledge of the maintenance issues in the resident rooms. Up until recently, the facility kept no records or tracked the status maintenance orders.

Based on the observations and staff and resident interviews made during today’s visit, deficiencies will be cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted. A copy of this report was reviewed, discussed then provided to Facility Representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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Document Has Been Signed on 07/18/2023 02:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Administrator and Care Coordinator agree to have the resident's window shades replaced, the resident's carpet shampooed and towel rack in the restroom repaired within the next 30 days. Administrator agrees to submit proof the repairs were made to the Community Care Licensing Office within the next 30 days.
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Based on observations and interviews, Administrator did not ensure the residents' room was kept in good repair at all times. Which poses poses a potential Health, Safety or Personal Rights risk to persons in
care.
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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: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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