361800147-10-5-2023-56-AS-NBRN-CWPNEU-20231017102432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 08/22/2023
Date Signed: 10/05/2023 11:30:08 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
08/18/2023 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230818153950

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:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Gwen Galvan, Care Coordinator Asst.		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff did not prevent resident from being a victim of financial abuse by an unknown perpetrator.
Staff did not dispense resident's medication as prescribed
Medication was falsely recorded as being refused by resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman (LPA) arrived to the Montclair Royale Senior Living unannounced to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator Assistant, Gwen Galvan to discuss elements of the allegations.During today's visit, LPA conducted staff and resident interviews, a walk through of the facility and collection of pertinent documents.

It is alleged that staff did not prevent resident from being a victim by an unknown perpetrator. During interview, with R1, it was reported that R1 put a large sum of cash in her nightstand; approximatley, $700. This was reported to staff who contacted Law Enforcement for assistance. Staff interviews revealed that this incident occured in December 2022. The Montclair Police Department was contacted and made a visit to the facility. Police determined there was not enough evidence to make a report or pursue the theft.
Please see LIC9099-C

Unsubstantiated

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: 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)

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Control Number 56-AS-20230818153950

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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During the facility visit, LPA made three different attempts to interview R1 in her room, unsuccessfully. While doing so, LPA observed that on each occasion, residents' kept their door wide open. The room is on the bottom floor near the lobby. The door opens up to a busy hallway. Resident's use this hallway to get the court yard and dining rooms.

It is alleged that staff did not dispense resident's medications as prescribed and medications are being falsely recorded as a refusal by resident. Staff interviews revealed that residents who are prescribed insulin receive their injections in the presence of a Medication Technician for the purposes of safety and security.
Furthermore interview with S1 revealed that originally R1's medication was prescribed for 6am. S1 observed R1 was missing doses due to R1 being asleep at the time needed to take the medication. Record reviews revealed the prescription was modified. The time of the prescription was changed to a later time; allowing the resident to sleep in. LPA reviewed the facility's Medication Administration Record, (MARS) for R1. LPA observed no evidence indicating medications were not being administered as prescribed. Interview with R1 revealed that Medical Technician's used to bring the medications to her room, but that changed recently. Staff informed R1 she would need to go to the Medications Office to get her medications. She had no problem with the change, but a family member reported that she did not agree and expressed frustration.

Based on observations, interviews and record reviews, we have determined that 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, where this report was reviewed, discussed then provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 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)

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