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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 05/03/2021
Date Signed: 05/04/2021 07:51:38 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 106DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tricia Danielson contacted the facility to deliver an amended report. LPA met with Care Coordinator Araceli Soto and explained the purpose of the visit. On 4/21/2021, LPA issued a report of unsubstantiated findings for three (3) allegations following a complaint investigation. During today's visit, LPA issued an amended report of unfounded findings for one (1) of the those (3) allegations. LPA explained the reason for amending the report and reviewed the report with Soto.

An exit interview was conducted with Soto via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receipt of these documents. Soto has also agreed to sign the reports and return a copy to LPA via email and/or fax.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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