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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:56:05 PM

Substantiated


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
04/13/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230413141951
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: 101DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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1. Staff do not ensure that resident is accorded privacy while in care.
2. Staff do not ensure that the facility is in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to deliver findings of complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto.

It is alleged that staff did not ensure that the resident was accorded privacy while care was being provided. Interviews with residents revealed that the blinds from their two room windows were missing. The resident's room is located on the bottom floor adjacent to the entry way to the facility patio. When it becomes dark out, the room is illuminated, allowing a view into insde the resident room. This was reported to staff on several occasions, but was never addressed. On 4/14/23, at approximately 4pm, LPA observed the window blinds missing. Staff interviews revealed, that the facility does have a work order system in place. Residents will verbally report to maintenance staff what needs to be fixed, the maintenance staff member will fix it and record it in a binder kept at the front desk. Residents will also report to front desk staff what's broken, staff will complete a work order form and give it to maintenance to be completed. At this time, the maintenance department is comprised of one staff member. Please see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 5
Control Number 56-AS-20230413141951
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: 05/30/2023
NARRATIVE
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There are no records of when the missing window blinds were reported by the residents. There is only record of when it was fixed. Records show it was fixed on 4/14/23. There is no record of the amount of time that passed between when the item was reported broken and when it was fixed. As of today 5/30/23, at 11:15am, LPA observed the window blinds were replaced.

It is alleged that staff do not ensure the facility is in good repair. During the staff interviews it was reveled that the facility has a system for work orders to be processed and addressed. At this time and for the past 6 months or more, the maintenance department is comprised of one (1) staff member. The facility maintains a Service Log which is meant to keep track of work orders being reported and when they are completed. At this time, the facility does not keep track of the progress of those work orders. For example, maybe a task requires a special part or tool in order to be fixed or addressed, there is no record of what has been done or what is needed in order to be fixed. Because progress of these work orders are not being tracked, there is only 1 maintenance staff member and there is a high volume of residents in care it is likely that some work orders do not get fixed in a timely manner.

We have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and provided to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/13/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20230413141951

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: 101DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
1. Staff do not ensure the facility is sanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to gather more information regarding the complaint allegation above and deliver findings. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto.

During today's visit, LPA made observations of the facility and conducted staff/resident interviews.
It is alleged that staff do not ensure the facility is sanitary. Staff interviews revealed that the facility employs several housekeepers. Housekeepers work 6 days a week. Their workload is split up among each floor of the facility. Housekeepers are responsible for cleaning the bottom floor lobby, bathrooms and other high volume areas, resident's rooms and anything asked of by management. Resident and Staff interviews revealed conflicting perspectives. There was no record of a toilet being broken in the resident room. During the visit, LPA observed housekeepers throughout the facility cleaning resident rooms and bathrooms. LPA observed the hallways, kitchen and high traffic areas appearing clean and unobstructed.
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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230413141951
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: 05/30/2023
NARRATIVE
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We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230413141951
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: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2023
Section Cited
HSC
80087(a)
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80087 - Buildings and Grounds- (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
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Licensee/Administrator agrees to make changes to the work order system to better address how work orders are processed in order to address resident needs. Administrator/Licensee agrees to have residents or staff complete a work order form when the resident reports something to be fixed.
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Observations of the residents room windows missing a number of blinds. Observations of no record of the window blinds being reported. This poses a potential Health, Safety or Personal Rights risk to persons in
care.
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Administrator/Licensee agrees to adopt this change from this day (5/30/23) forward.
During visit, staff made changes to the way in which work orders are placed and progress can be tracked.
Type B
05/30/2023
Section Cited
HSC
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance...
This requirement was not met as evidenced by:
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Administrator agreed to have the missing window shades replaced by the maintenance staff. As of 5/30/23, the resident's window shades have been replaced, verification submitted to Community Care Licensing. The plan of correction has been completed.
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Based on observations of the resident room and resident interviews the resident was not accorded personal privacy while care was being provided and the window shades were missing. This poses a potential Health, Safety and Personal Rights risk to persons 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: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5