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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 07/31/2023
Date Signed: 08/31/2023 01:25:49 PM

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
07/27/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230727151227
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: 127DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not inform resident's responsible party of incident(s).
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to initiate a complaint investigation into the allegations listed above. LPA signed in and met with Care Coordinator, Araceli Soto.

It is alleged that staff did not inform resident's responsible party of incident(s). Interview with staff revealed that two (2) incidents occurred between residents and responsible party was informed. LPA observed an incident report with a notation that responsible party was notified. Interview with responsible party denies receiving any notification about the incidents. Interviews with staff, resident and responsible party revealed conflicting information regarding if incident was reported to responsible party. Due to conflicting interviews, the allegation, staff did not inform resident's responsible party of incident(s) is unsubstantiated.
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: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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 2
Control Number 56-AS-20230727151227
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: 07/31/2023
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: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2