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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:52:29 AM

Substantiated


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
11/20/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231120222148
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: 131DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Melissa Mena, PM Supervisor & Gwen Galvan, Admin. Asst.TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living, Residential Care Facility for the Elderly unannounced to deliver the findings of the complaint investigation into the allegation listed above.

It is alleged that the facility illegally evicted a resident from the facility. During staff interviews, LPA discovered that R1 was taken to the hospital, as the hospital was attempting to discharge the resident the facility was contacted. Staff reported to the hospital that the resident could not return based on the level of care she would require. A reappraisal was not completed before making arrangements to relocate the resident. Without the reappraisal, staff did not have an opportunity to assess the resident to determine what services the facility could or could not provide. Staff denied offering to accept the resident back into care for an additional fee of $1000. Interviews with the witness revealed that the resident went to the hospital and was subsequently relocated to another facility. Which did not give the resident and family the required 30 day notice to make such relocation efforts.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 5
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
11/20/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20231120222148

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: 131DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Melissa Meena, PM Supervisor & Gwen Galvan, Admin. Asst.TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living, Residential Care Facility for the Elderly unnanounced to deliver the findings of the complaint investigation into the allegation listed above.

It is alleged that staff did not safeguard resident's personal belongings. During the witness interview, it was reported that R1 was admitted to the facility with clothing, a television, medical equipment, dentures, and glasses. Staff interviews revealed that the facility staff located the resident's clothing, dentures, but no glasses. Staff packed up R1's belongings, and notified R1's family, but the resident's family did not pick up the resident's belongings. A review of records revealed that the Resident's Personal Property & Valuables list did not claim the resident was admitted with any belonings. The document contained a strike across the columns with the word, "waived" written across, then signed at the bottom.

Please see LIC9099-C
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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20231120222148
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: 12/14/2023
NARRATIVE
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Based on record reviews and conflicting statements, the allegation is 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 where this report was reviewed, discussed and then provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20231120222148
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87224(a)
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87224. Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons...Thirty (30) days written notice to the resident is required...
This requirement was not met as evidenced by:
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Administrator agrees to complete an In Service Review with a sign in sheet with staff who are involved in making the decisions to retain, discharge or evict residents. Additionally, Administrator and staff will complete a statement of understanding by way of a LIC9098. Administrator agrees to submit Verification of the Inservice and LIC9098 form to community care licensing within the following business day.
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Based on record reviews and interviews the Administrator did not comply with the regulation listed above when the resident was relocated without a proper 30 day eviction notice. This posed an immediate Health, Safety and Personal Rights risk to persons 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20231120222148
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: 12/14/2023
NARRATIVE
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Based on record reviews and interviews, we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative. ** A Civil Penalty assessment accompanies the deficiency. **
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5