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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 06/28/2023
Date Signed: 06/28/2023 02:03:41 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
05/11/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230511112540
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
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to provide a safe and comfortable environment for resident
Staff failed to safeguard resident's personal belongings
Staff failed to reimburse resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst, Amber Coleman, (LPA) arrived to the Montclair Royale Senior Living Facility unannounced to deliver findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto and stated purpose of the visit. The investigation included staff, resident, and witness interviews, collection and review of resident files/documents.

It is alleged that staff failed to provide a safe environment for the resident. Witness and Resident (R1) interviews revealed that the resident moved in and was placed with another Resident (R2). The two (2) residents shared a conflict with one another that resulted in a physical altercation. Facility staff separated the two residents by finding another room for R1. The Police were called. Police determined that there was no action to be taken because both residents involved had assaulted one another. Staff interviews were consistent with the witness and R1’s interviews. According to the facility’s, “Theft and Loss Policy”, “…upon request and at the expense of the resident provide a look for the resident

Please see LIC9099-C**
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20230511112540
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: 06/28/2023
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
26
27
28
29
30
31
32
Bedside drawer or cabinet.” Staff reported a lockbox was not provided to the resident, because R1 had not made a request for a lockbox. Additionally, the resident was not paying an extra fee for a lockbox to be provided.

It is alleged that staff failed to safeguard resident’s personal belongings. While interviewing R1 and the witness, LPA learned that; after R1 was relocated to the new room, R1 was given $150 in cash. After spending an amount of the cash; it was put away in his room within his belongings. R1 left for the day and returned to find that the cash was no longer in his room. R1 brought this to the attention of staff.

Staff suggested R1 contact the Police to make a report. R1 refused to call the Police with the claim that R1 would not get their money back. R1 also reported that while staff was assisting him with moving his belongings to this new room, all of belongings were not moved. Staff interviews revealed that photos were taken to catalog the relocation. During the move the resident signed and stated a statement in agreement confirming that all his personal belongings were moved to the new room. During a review of records, R1’s Personal Property/Valuables Form, the resident had “no valuables” listed. The form is not dated, therefore it is not complete.

It is alleged that staff failed to reimburse the resident. After R1 informed management staff of incident, management and the Corporate Office agreed to reimburse the resident the cash that was allegedly stolen from his room in the amount of $80.00. Although, it was 2 months before management honored the request the resident was reimbursed in cash in the amount of $80.00 on 5/16/2023. Also, during this process Management had initially agreed to reimburse the R1 in the form of a check. R1 expressed that he currently had no state identification and would be unable to cash the check if given to him. Management also honored this request.

Based on staff, resident and witness interviews, review of records and observation, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted with Araceli Soto, Care Coordinator, this report was reviewed, discusses and provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2