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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:08:45 PM


Document Has Been Signed on 08/31/2023 01:08 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: DATE:
08/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) conducted an unannounced visit for complaint# 56-AS-20230825163400. During this visit, LPA observed deficiencies not related to the complaint allegation.

LPA completed a walk through of resident rooms on the facility's second floor. The section of the facility used for the Memory Care Unit. At approximately 11:14am, LPA observed what appeared to be human fecal in the cabinetry of a resident room.

At approximately 11:15am LPA observed the resident restroom located inside the resident room. The door was not secure. LPA walked inside and observed the bathtub to have debris along the walls. The debris was dark gray in color. This debris was in bits and pieces along the walls and floor of the tub.

At approximately, 11:16am LPA observed the resident window. The resident window was slightly ajar with mechanisms in place to keep the window from opening all of the way. LPA observed a screen attached to the window. The screen was weathered, damage and not secure; allowing unsecured access outside a second floor window.

Based on today's inspection, observations and interviews, deficiencies will be cited to address above mentioned concerns. Deficiencies noted on LIC809, LIC809D. An exit interview was conducted where this report was discussed, reviewed, then provided to facility representative; along with the appeal rights.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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 3


Document Has Been Signed on 08/31/2023 01:08 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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87303(f)(1)

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87303 Maintenance and Operation
"(f)Solid waste shall be stored and disposed...(1)Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease..."
This requirement is not met as evidenced by:
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Administrator agreed to have the resident's room thoroughly cleaned during LPA visit Administrator agrees to have staff check on the resident and the room every 30 minutes.. POC has already been completed on 8/31/23
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Based on observations, the Administrator failed to uphold the requirement listed above by not properly disposing of a resident's solid waste which poses an immediate Health, Safety and Personal Rights risk to persons in care.
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Type A
08/31/2023
Section Cited
CCR87303(c)

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87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement was not met as evidenced by:
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Administrator agrees to have the window screen replaced with a screen free of damage, that can be secured to the resident's window.
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Based on observations, the Administrator failed to have the resident's window repaired when it became weathered and damaged causing the resident access outside a second story.
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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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/31/2023 01:08 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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Administrator agrees to have the resident's bathroom cleaned and maintained by housekeeping staff. Administrator was able to have this completed during the visit. POC has been completed on 8/31/2023. Administrator also agrees to read and review the mentioned regulation, complete a
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Based on observations, the Administrator failed to keep the resident's bathroom clean, safe and sanitary. This poses a potential Health, Safety and Personal Rights risk to persons in care.
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statement of understanding by way of an LIC9098 form and submit it to the community care licensing office with in the next 7 days.

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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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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