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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:37:59 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200406090857
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: 129DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Araceli Soto, Care Coordinator TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident missed medical appointment resulting in requiring emergency treatment.
Facility is allowing resident to leave unassisted.
Facility staff not following physician's orders
Facility not maintained clean and sanitary
Resident's nutritional needs not met at facility
Facility is not assisting resident with medical care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA met with the facility Care Coordinator, Araceli Soto and explained the purpose of the visit and the elements of the allegation. The allegation(s) were investigated and consisted of observations, interviews and records review.

Regarding the allegation resident missed medical appointment resulting in requiring emergency treatment, it was alleged that Resident 1 (R1) missed several medical appointments resulting in R1 needing emergency treatment. R1 utilized and received services through a third-party transportation company. Facility staff are provided the transportation schedule. R1 requires medical treatments on Tuesdays, Thursdays and Saturdays. R1 had an appointment scheduled for 03/21/2020, however the third-party transportation never came to pick R1 up. A review of R1’s Post Treatment Form, dated 03/21/2020, corroborated the prescribed treatment was not given on this date. A review of R1’s Post Treatment Form, dated 03/24/2020, indicated R1 did receive the prescribed treatment on this second date.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 4
Control Number 18-AS-20200406090857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 11/27/2023
NARRATIVE
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It was also alleged R1 missed a medical appointment on 02/26/2020. Interview with witness revealed R1 chose not to attend the medical appointment. A review of the Facility Shift Report dated 05/22/2020, the third party transportation company did not pick R1 up for a medical appointment. Facility staff denied R1 required or received emergency treatment for any of the missed medical appointments. However per Facility Shift Report dated 3/2/2020, R1 was sent out due to their wound bleeding excessively and leaking through the gauze. The department was not able to obtain corroborating documents regarding the emergency treatment either from witnesses or other third-parties. Therefore, this allegation is unsubstantiated at this time.

Facility is allowing resident to leave unassisted It was reported that R1 was allowed to leave the facility unassisted when going to their medical appointments. R1 is ambulatory and per their physician’s reported dated 3/26/2020, R1 is unable to leave the facility unassisted. R1 did not have any reported eloping incidences and utilized a third-party transportation company to go to their appointments. An interview with the facility administrator revealed that there was a time when the third-party company was not coming inside to sign the residents out, the resident was not leaving unattended, as there was facility staff present in the lobby. This matter was addressed per the facility Administrator, as it was brought to the transportation company Director’s attention. After the matter was addressed, the third-party company staff would come inside the facility to pick up the residents. In addition, the facility policy is for all residents are to sign themselves in and out on the facility’s logbook. Based observation and interviews the allegation of facility is allowing resident to leave unassisted is unsubstantiated at this time.

Facility staff not following physician's orders It was reported that R1 had a doctor’s order for wound care and that the ordered ointment was not being placed on the wound. Per the interview with the Administrator Ann Marie Santos. Ms. Santos stated that R1 had a diabetic wound which was not stageable and that have never been without home health. Ms. Santos stated that the diabetic wound has always been overseen by medical provider who provides R1 with a Home Health Nurse, who will come and place the ointment on the wound and are responsible for the care of the wound. Ms. Santos stated that the facility is not qualified to care for the wound due to it being a diabetic ulcer. Ms. Santos is not aware of R1 ever being without Home Health and was not aware that he ever missed the ointment being placed on the wound. In addition, Ms. Santos stated that R1 was sent out to the hospital in March because the wound was not healing even with the ointment being placed on the wound. Further included in the doctor’s order on around 3/25/20, The doctor ordered for R1 to be isolated at facility for a condition that was ***Continued on 9099C

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20200406090857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 11/27/2023
NARRATIVE
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classified as "transferrable or contagious". During this time R1 did have a roommate, however It is important to note that during this time there was a pandemic and resources such as hospital beds were limited. The facility was encouraged to care for the resident at the facility as R1's condition at the time did not require hospitalization. It was further reported that facility staff also failed to follow universal precautions by not wearing gowns and masks while caring for resident. Per staff interviews conducted the proper protective equipment such as masks, gloves and gowns were worn when caring for R1. There was no evidence to corroborate what was alleged. Due to lack of evidence to show the alleged violation occurred the allegation of facility staff not following doctors orders is UNSUBSTANTIATED.

Facility not maintained clean and sanitary

It was reported that on or around March 2020, that there were feces on the door in R1’s room. Per the housekeeping staff, housekeeping services for R1 occurred daily. The services noted were daily trash pickup, towel change, toilet paper replenished, make or change bedding, vacuum, toilet, mirror, sink and polish. However, if there is an area that required cleaning that was not observed by housekeeping staff, it should be brought to the facility staff’ attention, so that the proper steps could be taken to address the area in need of cleaning. Per staff interviews R1 having feces on the door was something that occurred often, as it was a side effect that was experienced after R1 took their morning medication. If facility staff had knowledge of the area in need, then it would have been addressed. Based on interviews the allegation is UNSUBSTANTIATED.

Resident's nutritional needs not met at facility.

It was reported that R1 was being served only toast and an egg during breakfast. R1 is on a low carb diet, and would want items such as tater tots instead of the fruit that they were given. It was explained by the Administrator Ms. Santos and Chef to R1 as well as other relevant parties that because R1 is on a prescribed low carb diet, they will either be offered a small amount of the item served or an alternate altogether. Per the facility’s alternate menu for R1. R1 was served meals that were in accordance with suggested food guidelines, R1 was provided with fruits, vegetables, grains, protein and dairy. Based on interview and record review the allegation of resident nutritional needs not met at the facility is UNSUBSTANTIATED.

****Continued on 9099 C.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200406090857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 11/27/2023
NARRATIVE
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Facility is not assisting resident with medical care.

R1 received their medical services through a medical provider company. R1 had standing medical appointments three times a week. The facility staff would assist the resident with giving reminders for their upcoming appointments, and provide any updates that were provided to them. During an interview conducted with the Administrator Ms. Santos, R1 had a lapse in their insurance which in turn affected their services with the medical provided company. However, the facility nor was R1 responsible for their medical information. Once the individual responsible for R1’s medical information was made aware of the lapse in services, the issue was rectified and there were no further incidences, throughout the time of R1 being placed at the facility. R1 was noted to still receive services from Home Health. Based on interviews the allegation of facility is not assisting resident with medical care is Unsubstantiated. A finding of unsubstantiated means that 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, where a copy of this report was reviewed and provided to Araceli Soto.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4