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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 05/31/2023
Date Signed: 08/31/2023 01:58:07 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
03/30/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230330093256
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:
05/31/2023
UNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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1. Facility did not safeguard resident's personal property.
INVESTIGATION FINDINGS:
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During staff interviews, LPA learned that Resident #1, (R1) moved into the facility on August 25th, 2022. R1 and his family worked together to complete an Admissions Packet which included the facility's House Rules and a Pre Appraisal form. The documents were signed on 8/25/22 which signified that the house rules were understood and would be followed by R1. The Pre-Appraisal form indicated that R1 entered the facility with no belongings of substantial value, this document was also signed on 8/25/22.

It is alleged that the facility did not safeguard the resident's personal property. LPA observed an Incident report dated on 3/15/23 which indicated R1 suffered a medical emergency and had to be taken to the Hospital. When Medical Staff arrived, they had a hard time getting to R1 due to the amount of clutter in the room. When R1 returned to the facility from the hospital, he alleged the facility had stolen his property. During interviews with staff and R1, LPA learned that the items removed from R1's room were what is considered contraband. Staff confiscated the items and put them in a secure storage room. R1's account of the items was consistent with staff's account. The facility will release R1's items at the time he
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: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
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 4
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
03/30/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230330093256

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:
05/31/2023
UNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
1. Illegal Eviction
INVESTIGATION FINDINGS:
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Licenisng Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to deliver findings of the complaint investigation into the allegations listed above. LPA met with Araceli Soto, Care Coordinator; introduced self and stated purpose of the visit.

It is alleged that the facility is pursuing an illegal eviction of a resident. During staff interviews, LPA learned that Resident #1, (R1) moved into the facility on August 25th, 2022. The documents were signed on 8/25/22 which signified that the house rules were understood and would be followed by R1. LPA reviewed and observed the Eviction Notice provided to the resident and found that the document included the wrong contact information listed for the Long Term Care Obudsman. Therefore the facility did not provide the correct information to the resident; which makes the evicition illegal.

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.
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: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 4
Control Number 56-AS-20230330093256
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: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2023
Section Cited
CCR
1569.683(a)(2)
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ยง1569.683 Eviction notices; reasons for eviction contents; service
(a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction...the notice to quit shall include all of the following:(2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations.
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The plan of correction has been addressed, the Administrator re-issued a corrected eviction notice for R1. LPA observed the corrected eviction notice.
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This requirement was not met as evidenced by:
Based on record reviews and interviews, the Administrator illegally issued an eviction notice to the resident when the wrong contact information was given as a resource. 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 56-AS-20230330093256
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: 05/31/2023
NARRATIVE
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 The facility will release R1's items at the time he successfully moved out of the facility.

Based on interviews, observations and records reviews, 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: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4