361800147-7-24-2023-56-AS-NBRN-CU6QC5-20230728120233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:09:47 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2023 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230623110652

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: 125	DATE:	07/24/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	AnnaMarie Santos		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff did not inform resident's authorized person of changes to resident's care/placement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to the facility to continue the complaint investigation and deliver findings on the above allegation. LPA met with care coordinator assistant Gwen Galvan who was informed of the purpose of today’s visit. Administrator Annamarie Soto arrived during the visit. The investigation consisted of staff interviews and records review. LPA was unable to speak with Resident (R1).

It is alleged that Staff did not inform resident's (R1) authorized person of changes to resident's care or placement. LPA reviewed records showing that R1 previously resided at this facility from 10/05/2021 through 06/11/2023. Records reviewed show that R1 was under the care of the San Bernardino County Office of the Public Guardian (PG). Interview with staff reveal that the facility contacted the PG as early as 06/09/23 due to R1 attempting to self admit at a medical facility for experiencing hallucinations. LPA reviewed records from 06/09/23 through 06/11/23 noting R1's aggressive and harmful behaviors and the facility contacting the PG daily. Records further revealed that on 6/11/23 R1 was taken and held at a hospital and on 6/12/23 R1's

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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 56-AS-20230623110652

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
, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
	VISIT DATE: 07/24/2023

NARRATIVE

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healthcare case worker notified this facility that they have been in touch with the PG about R1's hospital admission and finding an appropriate placement for R1.

Based on the information obtained from records review and interview conducted, the above allegation is 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 and a copy of this report was provided to .

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC9099 (FAS) - (06/04)

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