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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:26:19 PM


Document Has Been Signed on 08/17/2023 02:26 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:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gwen Galvan, Admin. StaffTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 8/15/23. The incident involves a resident in care who gained access to and consumed perfume. LPA met with Administrative Staff, Gwen Galvan. LPA introduced self and stated purpose of the visit.

Today's visit consisted of collection of pertinent documents, a walk through the resident's floor and assigned room and staff interviews. LPA observed three to four staff members on the floor at the time of the visit. LPA asked staff to show LPA were the chemicals and toxins are kept to inspect the area. Staff escorted LPA to the floor's dining area where two white cabinets are housed. The cabinets stood approximately 4 feet tall. Each cabinet has double doors. They each have the equipment necessary to secure the cabinet. At approximately 1:25pm, LPA observed the two cabinets and observed that while the doors were shut, the locks were not engaged, making it accessible to residents in care.

Based on observations and interviews, one deficiency will be cited per Title 22, Division 6, of the California Code of Regulations. An exit interview, was conducted where this report was discussed, reviewed and provided to Facility Representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/17/2023 02:26 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
87309(a)

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87309 - Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by:
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Licensee agrees to conduct another staff training regarding maintaining secure storage of chemicals on 8/23/23. Licensee also agrees to increase the amount of staff on the floor for additional supervision of the residents in care.
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Based on observations and interviews, the Licensee failed to keep the storage of chemicals and toxins inaccessible to residents in care. Which poses an immediate Health, Safety and or personal rights risk to resident 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: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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