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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:31:34 AM

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
06/29/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20230629154129
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: 125DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Araceli SotoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained an unexplained injury while in care of the facility.
Resident wandered away from the facility due to staff neglect.
Staff do not provide residents with daily activities.
Staff do not provide accurate information needed to ensure resident is receiving appropriate care
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale unannounced to deliver findings of the complaint investigation into the allegations listed above. LPA introduced self and stated the purpose of the visit then discussed the findings.

It is alleged that a resident sustained an unexplained injury while in care of the facility. Staff interviews revealed that R1 was scheduled for a dentist appointment at 8:30am. R1 had breakfast and left the facility at 6:40am via Innovage/PACE Transportation. Staff of Montclair Royale deny the incident occurred at the facility; reporting that no injuries were observed on R1 when she left for her appointment. Staff of Innovage reported that residents who arrive early to their appointments often wait at the Innovage Center in a courtyard unattended. It is unclear whether the lip injury occurred during her dentist appointment or possibly during her time in the courtyard at Innovage. Innovage staff investigated the matter and suggested the lip injury did not occur at Innovage due to lack of any incident report being submitted on or around the date of R1’s dentist appointment. LPA unable to reach R1’s family for interviews.

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: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
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 3
Control Number 56-AS-20230629154129
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: 10/05/2023
NARRATIVE
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It is alleged that resident wandered away from the facility due to staff neglect. LPA observed that R1 resides in the facility’s Memory Care Unit. The Memory Care Unit is a restricted unit in which staff need a key to enter and leave. A key is also required to use the elevator on the unit. During staff interviews, it was discovered that the memory care unit has an adequate amount of staff to care for the number of residents in care. Staff report that R1 did leave the memory care unit floor. R1 waited by the elevator, standing along side family members leaving the floor. The family didn’t know R1 was a resident of the memory care unit and allowed R1 to enter the elevator and leave floor. By all staff accounts, R1 did not leave the facility. R1 wandered around the first floor, never leaving the facility grounds. LPA unable to gather any information from R1 or family of R1.

It is alleged that staff do not provide resident with daily activities. During LPA’s walkthrough of the facility, LPA observed a Large Print Activities Calendar posted in the hallway of the memory care unit. Accessible to all residents to read and join an activity. LPA also observed the dining room with different activity materials for crafting. Across from the dining room is an Activity Room with adequate seating. Staff report the room is used for group activities such as exercising or watching television. Resident are free to go in and out of the room as they please. This room included adequate seating as well as board and card games. LPA received a copy of the Memory Care Unit’s Activities Calendar which was consistent with observations. Staff interviews revealed that staff take turns throughout the day to lead activities. Staff encourage residents to participate, but participation is not mandatory. Staff report R1 may start an activity but may get distracted get up and leave. Staff allow residents to come and go to avoid aggressive or combative behaviors.

It is alleged that staff do not provide accurate information needed to ensure resident is receiving appropriate care. Staff interviews revealed that R1 was taken to the hospital on two occasions. The first occasion was to address R1 injury. On the second occasion, R1’s daughter transported R1 to the hospital. A review of medical records and incident reports reflect that this occurred. Staff report that R1’s daughter was contacted to be notified of R1’s condition and current status but received no answer or returned call. On the second occasion, R1’s daughter was present during the hospital visit. Records also reflect ongoing communication between facility staff, R1’s daughter and Innovate staff. Innovage staff and R1’s daughter worked together to find better suited housing for R1 and closer to R1’s daughter. R1 officially moved out of the facility on 8/9/23. LPA was unable to reach R1’s daughter to obtain any other information or account of what occurred.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230629154129
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: 10/05/2023
NARRATIVE
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Based on the information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted with facility representative and a copy of this report was provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3