361800147-3-26-2021-18-AS-RLAY-C22KJM-20210413075654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 03/25/2021
Date Signed: 03/26/2021 04:17:50 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2020 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200922133006

FACILITY NAME:	MONTCLAIR ROYALE SENIOR LIVING		FACILITY NUMBER:	361800147
ADMINISTRATOR:	SANTOS, ANNAMARIE		FACILITY TYPE:	740
ADDRESS:	9685 MONTE VISTA AVE		TELEPHONE:	(909) 621-3545
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	236	CENSUS: 103	DATE:	03/25/2021
		UNANNOUNCED	TIME BEGAN:	04:04 PM
MET WITH:	Anna Marie Santos		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Lack of care and supervision resulting in resident engaging in self-harming behavior
Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pauline Beschorner conducted this investigation visit telephonically to conclude this agency’s investigation into the complaint allegations mentioned above. LPA spoke with Administrator Anna Marie Santos.

During this investigation, interviews were conducted with the Administrator, staff and relevant parties. A review of resident (R1) records was completed by LPA and copies of pertinent documents were obtained. LPA reviewed R1's physician's report, physician orders, admission agreement, and hospital records.

The allegation alleges lack of care and supervision resulting in resident engaging in self-harming behavior. Based on interviews with Administrator, staff and relevant parties' interviews revealed staff entered into R1's bedroom to assist with incontinent care and found R1 banging R1's head against a dresser next to R1's bed. When this happened staff immediately called 911 and R1 was sent out to the emergency room.
CONTINUED ON NEXT PAGE

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200922133006

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
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
	VISIT DATE: 03/25/2021

NARRATIVE

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R1 had never engaged in this type of behavior resulting in injuries to self. Based on record review, records indicated R1 was not self abusive but became aggressive and anxious due to a diagnosis of dementia. When R1 would become aggressive facility staff would notify R1's doctor and R1's family. The doctor would then adjust R1's medication. R1 would stop having aggressive behaviors for about 1 month and then the behaviors would start again. There is no evidence that there was a lack of care and supervision resulting in resident engaging in self-harming behaviors, therefore this allegation is unfounded.

The second allegation alleges resident sustained unexplained injuries while in care. Based upon record review R1 was sent out to the hospital on August 20, 2020. While in care at the hospital R1 had to be restrained due to combative behavior. When R1 returned to the facility R1 had bruises on R1's arms and wrists from the restraints. An incident report was sent into Community Care Licensing within seven days of R1 being sent out to the hospital. On August 27, 2020 R1 was found in R1's room banging R1's head against the dresser. Facility staff immediately sent R1 out to the hospital for injuries sustained. An incident report was submitted for incident within seven days of incident occurring. R1 did not have unexplained injuries all injuries were explained and documented; therefore, this allegation is unfounded.

This agency has investigated the complaints mentioned above. We have found the complaint to be unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was reviewed with and appeal rights were provided to Administrator Anna Marie Santos whose signature on this form confirm receipt of the above-mentioned documents.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

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