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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 11/17/2023
Date Signed: 11/17/2023 01:43:31 PM


Document Has Been Signed on 11/17/2023 01:43 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
11/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Gwen Galvan, Admin. Asst. & Araceli Soto, Care Coord.TIME COMPLETED:
01:50 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to conduct case management visit in response to a recent death of a resident while in care of the facility. LPA was greeted by Administrative Assistant, Gwen Galvan and Care Coordinator, Araceli Soto. LPA was asked to signed in and met with Araceli Soto. LPA stated the purpose of the visit.

During today's visit, LPA requested and collected pertinent documentation and conducted staff interviews to gather more information about the incident.

On 11/8/23, Community Care Licensing, San Bernardino received an Incident Report, (SIR) notifying the agency of the death of a resident.

No deficiencies was during today's visit. An exit interview was conducted where this report was discussed and provided to the Administrator.


SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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