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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:15:44 PM

Document Has Been Signed on 05/06/2022 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
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: 130DATE:
05/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:TIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst Anna Bueno conducted an unannounced visit to deliver findings for complaint numbers: 18-AS-20220105101235 and 56-AS-20220318083750. LPA met with Mikaila Tonan, receptionist, who was explained the purpose of today’s visit.

During complaint investigations, the Department discovered that eviction notices were given to Resident 1 and Resident 2. Refer to LIC-809D for deficiencies cited.

An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided to Mrs. Tonan.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2022 02:15 PM - It Cannot Be Edited


Created By: Anna Bueno On 05/05/2022 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2022
Section Cited
CCR
87224(f)

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A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement was not met as evidenced by:
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Licensee and staff shall review regulation section 87224. A statement of understanding of the regulations shall be provided to CCL by end of POC due date 5/9/2022.
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The Department did not receive notices of eviction until investigation of complaint #s 18-AS-20220105101235 and 56-AS-20220318083750.
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Type B
05/20/2022
Section Cited
CCR87405(a)

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All facilities shall have a qualified & currently certified administrator. The licensee & administrator may be...the same person. The administrator shall have sufficient freedom from other responsibilities & shall be on the premises a sufficient number of hours to permit adequate attention to the management & administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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Licensee submit to the Department an LIC308 and staff qualification and LIC507 showing Administrator's hours in the facility no later than end of POC due date 5/20/2022.
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This requirement was not met as evidenced by:

Based on interviews and observations, facility has not submitted an LIC308, Designation of Facility Responsibility, to the Department since Administrator went on medical leave/full time telework/on-call status on
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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
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
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