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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:47:37 PM

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
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: 116DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Lidya Wenny and Makaila TonanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Lidya Wenny and Makaila Tonan who confirmed there is 1 active Covid-19 case in the community. LPA toured the facility with Tonan.

The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point to the main lobby has a sign-in policy for universal entry screening. The facility also documents daily temperature and COVID-19 symptom checks for all visitors while residents are subject to routine symptom screening and regular observations for any change in condition. Continued weekly routine testing for staff is still observed. LPA observed all staff are properly fitted with face coverings.

LPA Bueno toured the facility’s common rooms and an empty private apartment currently housing Personal Protective Equipment (PPE) . Tonan stated that the COVID wing has 1 active resident and their roommate in isolation. LPA saw the COVID wing closed off by double doors and posted were necessary droplet precaution and COVID related signages. Wenny verified that the smoke and carbon monoxide detectors and fire alarms are maintained and monitored by an outside vendor. LPA viewed the maintenance log that showed the last visit was conducted on 8/29/2021. LPA observed hand sanitizer throughout the facility, mostly situated by the elevator and exit doors. Tonan also confirmed the facility has an adequate supply of cleaning and disinfectant provisions.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA Bueno gave a technical advisory regarding fit testing for staff in the Covid wing. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to Tonan at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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