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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 04/21/2021
Date Signed: 05/04/2021 07:55:15 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/05/2021 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-NP-20210405102752
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: 106DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Gwen Galvan, ReceptionistTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Licensee did not provide resident with clean towels
Facility carpet maintained unclean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson contacted the facility to conclude a complaint investigation. LPA identified herself and discussed the purpose of the call with receptionist Gwen Galvan who stated she was in charge at the time of the call. Regarding the allegation "Licensee did not provide resident with clean towels": It was alleged that although the facility cleans their towels, the towels could be more clean and aren't provided regularly. Of six (6) resident interviews conducted, six (6) of six (6) residents revealed they receive fresh clean towels on a regular basis and had no issue with the towels.
Regarding the allegation "Facility carpet maintained unclean": Of six (6) resident interviews conducted, five (5) of six (6) residents believe the facility does maintain clean carpets. Five (5) of six (6) residents interviewed reported their room carpet was clean and/or had just been cleaned within two weeks prior of LPA's visit, or has observed facility staff cleaning carpets in various areas of the facility. LPA observed several rooms and areas of the facility and although some areas/rooms exhibited soiling, it did not meet unacceptable standards. Records reviewed also revealed a regular schedule of carpet cleaning performed at the facility. Records reviewed indicated fifty-eight (58) occurrences of facility carpets being cleaned between January 2021 and April 13, 2021. (CONTINUED ON 9099 C) *This is an amended report*
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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 5
Control Number 18-NP-20210405102752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 04/21/2021
NARRATIVE
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(CONTINUED FROM LIC 9099)
The above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore these allegations are unsubstantiated at this time.
An exit interview was conducted with Galvan and a copy of this report was provided via email and an electronic email read receipt confirms receipt of the documents. Galvan has agreed to sign the report and send a copy back to LPA.
*This is an amended report*
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/05/2021 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-NP-20210405102752

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: 106DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Gwen Galvan, ReceptionistTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not respond to resident’s call button in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson contacted the facility to conclude a complaint investigation. LPA identified herself and discussed the purpose of the call with Receptionist Gwen Galvan who reported she was in charge at the time of LPA's call. Regarding the allegation "Staff do not respond to resident's call button in a timely manner": It was alleged that some facility staff take one (1) hour to respond to resident's call button. The investigation revealed the facility call button alarm sounds non-stop and was continually broadcast throughout the entire facility during LPA's visit. During a LPA test of the call button alarm in room 132, LPA found the call light to be malfunctioning and unable to stay triggered. This required LPA to continually apply pressure to the cord to enable the alarm. This was also observed by Care Coordinator Araceli Soto who then notified maintenence. LPA observed staff's response to the alarm took approximately fifteen (15) minutes. LPA also observed the responding assigned staff member to be absent of the facility radio which would have provided her with the notifcation of the alarm. Call light log records reviewed revealed the LPA triggered alarm was logged accurately but that the response time was logged as four (4) minutes later. This was not only inaccurate but improbable due to the assigned staff member not utilizing her radio. Of six (6) residents interviewed, three (3) stated they utilize or (CONTINUED ON LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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 5
Control Number 18-NP-20210405102752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
CCR
87468(a)
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Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by: The Licensee did not ensure
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The facility stated a training will be conducted with all caregivers to outline their responsibilites in responding to resident's call lights in a timely manner and the importance of utilizing their radio to allow notification of the call. Proof of training will be provided to LPA by April 30, 2021.
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resident's call light alarms were answered in a timely manner. Based on LPA observation and interviews which were conducted, resident call light alarms are not answered in a timely manner. This poses a potential health, safety and personal rights risk to residents 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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-NP-20210405102752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 04/21/2021
NARRATIVE
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(CONTINUED FROM LIC 9099-A)
have utilized the call button. All three (3) residents reported unacceptable response times. One (1) resident reported a wait time of two (2) hours and two (2) residents reported staff failed entirely to respond. Based on LPA's observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099 D.
An exit interview was conducted with Galvan and a copy of this report was provided along with Appeal Rights.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5