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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 08/10/2026
Date Signed: 08/10/2026 02:19:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
07/24/2026 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260724103234
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: 122DATE:
08/10/2026
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Anna Marie Santos, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff handle residents inappropriately
Facility is not sufficiently staffed to meet the needs of residents in care
INVESTIGATION FINDINGS:
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On August 10, 2026, at 12:40 PM, Licensing Program Analysts (LPA) Eldin Serrano visited the facility to investigate the above-mentioned allegations and deliver findings. LPA met with Administrator Anna Marie Santos to discuss the purpose of the visit. The investigation consisted of file/evidence review, interviewing relevant parties as well as observation.

Allegation: Staff handle residents inappropriately - Interviews with staff and residents consistently indicated that staff generally handle residents appropriately. One incident involving R1 was confirmed through video provided by R1’s daughter. The video suggested the caregiver could have handled R1 more appropriately, though the actions did not appear intentional. The caregiver was reassigned and retrained, therefore this allegation is substantiated.

*******continue on LIC9099C******
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
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 56-AS-20260724103234
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 08/10/2026
NARRATIVE
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Allegation: Facility is not sufficiently staffed to meet the needs of residents in care - Based on interviews with relevant parties, 7 out of 9 reported staffing shortages, particularly when caregivers call in sick and replacements cannot be secured. The Administrator confirmed ongoing hiring challenges and long processing times; therefore, the allegation is substantiated.

Based on interviews, and evidence reviews, the preponderance of evidence standard has been met, therefore, the allegation is substantiated under the California Code of Regulations (Title 22, Division 6 Chapter 8).

An exit interview was conducted where this report, LIC9099, LIC9099C, and LIC9099D along with appeal rights, were provided to the Administrator Anna Marie Santos.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20260724103234
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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: 08/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2026
Section Cited
CCR
87411(a)
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Title 22, Division 6 Chapter 8 87411 (a)
Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidence by:

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The Administrator will submit a revised staffing plan within 14 calendar days. The plan will include strategies for mitigating staffing shortages, ensuring coverage during sick call-outs, and improving recruitment timelines.
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Interviews confirmed repeated staffing shortages impacting resident coverage in both assisted living and memory care. Staff reported that shortages worsen during sick call-outs and due to delays in hiring. The Administrator acknowledged ongoing challenges with recruitment and staff turnover, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
08/10/2026
Section Cited
CCR
87411(d)(3)
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Title 22, Division 6 Chapter 8 87411 (d)(3) Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.This requirement is not met as evidence by:

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Caregiver involved was reassigned and no longer cares for R1. Caregiver completed retraining on resident-handling procedures. Administrator will monitor caregiving practices to ensure ongoing compliance with personal rights and proper care techniques. Administrator already submitted the training conducted with the staff.
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Based on the video evidence provided by R1’s daughter it was clear that the staff needs to receive refresher training on safe handling practices and dignity in care, which poses a potential health, safety or 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: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
07/24/2026 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260724103234

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: 122DATE:
08/10/2026
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Anna Marie Santos, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff do not treat residents with dignity
INVESTIGATION FINDINGS:
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On 8/10/2026 at 1:40 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA explained the purpose of the visit to Administrator Anna Marie Santos. The investigation consisted of interviews with staff and clients as well as observation.

Allegation: Staff do not treat residents with dignity – All resident and staff interviews confirmed residents are treated with dignity and respect. LPA did not find evidence to support this allegation.

Based on the evidence, the allegations mentioned above is UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to administrator Anna Marie Santos.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4