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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 08/22/2023
Date Signed: 09/13/2023 12:46:59 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
02/06/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20230206124429
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: 112DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gwen Galvan, Care Coordinator AssistantTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff did not assure resident have hot water to shower.
Resident's roof is in disrepair.
INVESTIGATION FINDINGS:
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Licesning Program Analyst, Amber Coleman arrived at the Montclair Royale Senior Living Facility to unnannounced to deliver the findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Administrator, AnnaMarie Santos, to discuss elements of the complaint.

It is alleged that facility staff did not insure residents had hot water to shower. During staff interviews, LPA learned that the facility's boiler stopped working properly between 1/30/23 and 2/3/23. Maintenance staff examined the boiler and determined a part was required in order to fix it. Receipts from Ferguson Enterprises indicate, new part was ordered on 2/4/23, picked up on 2/5/23 and the facility boiler was fixed by 2/6/23 restoring hot water to the facility.

It is alleged that the resident's room is in disrepair. Resident and staff members statements were consistent. The resident's room had a water leak in the ceiling. LPA also observed evidence of a water leak on the resident's room ceiling. LPA observed the resident's room ceiling to have a number of brown
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: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
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 6
Control Number 56-AS-20230206124429
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: 08/22/2023
NARRATIVE
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circular stains right above the resident's bed. According to building records, the facility's air conditioning units do leak water/fluid when in use on occasions. The maintenance staff will address these water leaks with priority when reported. Also, observed were towels on the floor, positioned under the stains seemingly to catch the fluid as it drops from the ceiling. LPA observed a white material over the stain as if it were patched. The ceiling was not actively leaking during LPA observation.

Based on LPA’s interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D. An exit interview was conducted where this report was reviewed, discussed, and a copy was provided to facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20230206124429
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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
HSC
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The plan of correction has already been addressed as the facility is and continues to patch leaks in and around the facility.
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04/14/2023
Section Cited
HSC
87303(e)(2)
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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: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20230206124429
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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
Section Cited
CCR
87303(e)(2)
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87303 Maintenence and Operation (e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water.
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Plan of Correction was completed on 2/6/23 when the facility's boiler was fixed resuming hot water to residents in care.
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Based on interviews and record reviews the Administrator did not insure the facility provided hot water to residents for personal care which 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: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
02/06/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230206124429

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: 112DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gwen Galvan, Care Coordinator AssistantTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff damaged resident’s clothes.
Facility staff served resident cold meal(s).
Facility staff did not keep resident’s room free from pests.
INVESTIGATION FINDINGS:
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Licesning Program Analyst, Amber Coleman arrived at the Montclair Royale Senior Living Facility to unnannounced to deliver the findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Administrator, AnnaMarie Santos, to discuss elements of the complaint.

It is alleged that staff damaged resident's clothes. Staff interviews revealed that the facility will provide laundry services to its residents. Residents have the option of washing their own clothes using the facility's washers and dryers. Lastly, residents have the option of allowing their families to do the resident's laundry. These services are discussed and arranged during the resident's move in.

It is alleged that facility staff serve cold meal(s). During resident interviews, LPA learned that resident meals are delivered to resident rooms. Residents can also dine in the dining room or pick up their meals and take their meals to go. Additionally, residents can purchase their own meals and keep them in their room. Staff interviews revealed that the residents have their meals delivered to their rooms on a
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: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20230206124429
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: 08/22/2023
NARRATIVE
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tray. The facility care for residents with varying ambulatory statuses. Depending on how long it takes a resident to get to the door, their food could be waiting outside their room for five to ten minutes; which allows time for the food to cool. Record reviews, LPA discovered that all dietary staff have the proper Food Service/Handling Training.

The facilities laundry room houses washers and dryers that automatically dispense laundry detergent to the wash basin. This device is secure and is only serviced by maintenance staff. Staff reports that bleach isn't used in resident laundry rooms. Staff denies having knowledge of or witnessing any recent incidents involving damage to residents clothing. LPA was unable to observe any laundry said to have been damaged by facility laundry services. LPA interviewed four, (4) residents, three (3) out of 4 residents denied suffering any damage to their clothing due to facility laundry services.

It is alleged that facility staff did not keep resident's room free of pests. LPA completed a walk through of the facility and observed no evidence of pests in the facility. LPA did observe that residents are permitted to keep food in their rooms. Staff advises residents to keep food containers sealed/closed to prevent pest problems. Staff reported and LPA observed that some residents have their own refrigerators and microwaves in their rooms. Housekeeping aids residents in cleaning their rooms on a weekly basis. During staff interviews, it was discovered that the facility contracts pest control services. Pest control services the facility twice a month and on call as needed. Residents are encouraged to report any pest problems to the front desk; alerting staff to contact Pest Control to book additional appointments.

Based on the information recorded above, 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: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6