361800147-7-28-2023-56-AS-EMAN-CU9LTY-20230731090305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 07/28/2023
Date Signed: 07/28/2023 09:54:51 AM

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
12/28/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221228154401

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:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Araceli Soto- Care Coordinator		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Staff did not properly assist resident with their medication.
Facility kitchen is in disrepair.
Facility has rodents.
Resident's dietary records are not maintained.
The water temperature is not within the required range of 105 F to 120 F.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Care Coordinator Araceli Soto. The investigation consisted of resident interviews, staff interviews, document review, and a facility tour.

For allegation, Staff did not properly assist resident with their medication:

It was alleged that two (2) residents (R1 & R2) did not get assistance with refilling their medication in a timely manner. Interviews with staff and document review revealed that there was an uncontrollable shipping delay with the shipping partner that the pharmacy uses to deliver medications. The pharmacy and the facility worked together to resolve the issue by using an alternative shipping company.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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 6

Control Number 56-AS-20221228154401

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: 07/28/2023

NARRATIVE

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For allegation, Facility kitchen is in disrepair:

Facility tour and interviews with staff revealed that the freezer door in the kitchen was broken. The freezer door closes but it must be pushed hard to ensure the door latches correctly. The facility has been proactive and ordered a new freezer door. The facility issued payment to a company on 10/27/2022. There were issues with the company completing the work after the payment was issued. The facility had to take the company to small claims court to resolve the issue. The facility found a new company and a new freezer door was installed on 6/23/2023. Document review and interviews with staff revealed that the facility has a contract with SMC Grease Specialists. The company comes to the facility to clean and remove the grease from the oven and the stove. In between visits, the facility staff cleans the surface of the oven and stove.

For allegation, Facility has rodents:

Interviews with residents and staff revealed that the residents and staff have not seen rodents at the facility. Document review of pest control statements dated September 2022, October 2022, and November of 2022 revealed that the facility has monthly pest control treatments completed by Dewey Pest Control to ensure the facility prevents rodents. If there is a complaint of pest or rodents, the staff stated that they are proactive, and call Dewey Pest Control out to the facility to complete a follow-up treatment to resolve the issue.

For allegation, Resident's dietary records are not maintained:

Interviews with staff and document review revealed that the facility maintains dietary records in the kitchen, as well as in the facility office in the resident’s individual files.

For allegation, the water temperature is not within the required range of 105 F to 120 F:

During the facility tour, LPA observed the water temperature to read within the required range at 115 degrees Fahrenheit.

Overall, there was not enough evidence to collaborate the allegations listed above.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 56-AS-20221228154401

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: 07/28/2023

NARRATIVE

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Based on evidence obtained during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Care Coordinator Araceli Soto, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
12/28/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221228154401

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:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Araceli Soto- Care Coordinator		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Residents are not provided proper food service.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Care Coordinator Araceli Soto. The investigation consisted of resident interviews, staff interviews, document review, and a facility tour.

For allegation, Residents are not provided proper food service:

Interviews with staff and residents and document review revealed that the facility was not providing proper food service to the residents. The residents were being served food at the incorrect temperature, residents were not receiving meals at the correct time, there were instances of residents not receiving a meal, residents were being served items that they were not approved to eat, and portions sizes of food were the incorrect size.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 56-AS-20221228154401

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: 07/28/2023

NARRATIVE

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Based on evidence obtained during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because of the preponderance of evidence the standard has been met.

During today’s visit, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Care Coordinator Araceli Soto, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 56-AS-20221228154401

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/31/2023 Section Cited CCR 87555(b)(17)	1 2 3 4 5 6 7	87555.General Food Service Requirements. (b)The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility.	1 2 3 4 5 6 7	The licensee has agreed to read regulation 87555 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee hired a qualified kitchen staff on 1/3/2023. The staff started working on 1/16/2023. The POC due date is 7/31/2023.
	8 9 10 11 12 13 14	Based on observation, interview and document review, the licensee did not comply with the section cited above evidenced by not employing a qualified kitchen staff to ensure the residents were provided with proper food service which poses a potential health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6