361800147-7-17-2023-56-AS-NBRN-CVSTMG-20230918145107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:41:42 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
07/11/2023 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230711095633

FACILITY NAME:	MONTCLAIR ROYALE SENIOR LIVING		FACILITY NUMBER:	361800147
ADMINISTRATOR:	SANTOS, ANNAMARIE		FACILITY TYPE:	740
ADDRESS:	9685 MONTE VISTA AVE		TELEPHONE:	(909) 621-3545
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	236	CENSUS: 127	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Gwen Galvan, Admin.. Staff		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint investigation into the allegation listed above. LPA introduced self to staff, singed in visitor's log and stated the purpose of the visit. LPA met with Administrative Staff Member, Gwen Galvan, who informed LPA Care Coordinator, Araceli Soto and Administrator, AnnaMarie Santos-Tabila were out of the facility. During the interaction, Gwen Galvan informed Care Coordinator, of LPA's visit.

During the visit, LPA met with staff and residents for interviews, collected pertinent documents, completed a walk through of the facility and delivered findings. Staff interviews and correspondence revealed that there was an attempt to evict a resident in care in 3 days; due to an increase in aggressive behaviors. Documentation collected revealed that the request to evict the resident in 3 days was not approved by the Community Care Licensing Office. Documentation further revealed that the 30 day eviction pursued afterwards was invalid. Therefore making the eviction illegal.
Please see LIC(9099)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230711095633

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: 07/17/2023

NARRATIVE

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Based on LPAs observations, interviews conducted, information collected, the preponderance of evidence standard has been met, therefore; 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 furnished to the facility representative.

Please see LIC 9099D.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230711095633

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: 07/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/17/2023 Section Cited HSC 87224(b)	1 2 3 4 5 6 7	Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator/Licensee agrees to complete a 30 Day Eviction correctly with applicable dates and re-issue the eviction to the resident's Power of Attorney. Administrator will also submit proof the Eviction Notice was issued to the Community Care Licensing Office.
	8 9 10 11 12 13 14	Based on interviews, collected documentations and onservations the licensee did not acquire the approval of a 3 day eviction from Community Care Licensing. The 30 day Eviction Notice pursued after the denial was invalid as it was not complete which which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14	Adminstrator agrees to work with the Long Term Care Ombudsman and Innovage, Social Worker to secure suitable, licensed care and housing for the resident in care. Administrator agrees to complete a LIC9098 self-certifying that the Eviction Procedure Regulation is understood. Each task is to be completed within the next 30 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 Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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