Montclair Royale Senior Living

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced visit to the Monclair Royale Senior Living Facility to deliver the findings of the complaint investigation. LPA met with Care Coordinator, Araceli Soto and stated the purpose of the visit. The investigation included interviews with staff and residents, a review of records and observations. It is alleged that staff does not ensure the resident has access to the resident’s wheelchair. Staff interviews revealed that R3’s wheelchair is kept in R3’s closet for the purposes of safety. During LPA’s visit, LPA made observation of R3’s room. LPA observed the wheelchair inside of the room outside of the closet. LPA accessed the wheelchair, opened it, pushed it, opened the foot pedals. The wheelchair appeared to be functional and in good repair. All staff report R3 has the ability to walk on their own on the floor. Photographic evidence depicted a wheelchair next to the resident’s bed, giving the resident access to the wheelchairRead the full finding— CDSS inspection report, October 16, 2023 · control 56-AS-20230503082338

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale unannounced to deliver findings of the complaint investigation into the allegations listed above. LPA introduced self and stated the purpose of the visit then discussed the findings. It is alleged that a resident sustained an unexplained injury while in care of the facility. Staff interviews revealed that R1 was scheduled for a dentist appointment at 8:30am. R1 had breakfast and left the facility at 6:40am via Innovage/PACE Transportation. Staff of Montclair Royale deny the incident occurred at the facility; reporting that no injuries were observed on R1 when she left for her appointment. Staff of Innovage reported that residents who arrive early to their appointments often wait at the Innovage Center in a courtyard unattended. It is unclear whether the lip injury occurred during her dentist appointment or possibly during her time in the courtyard at Innovage. Innovage staff investigated the matter and suggRead the full finding— CDSS inspection report, October 5, 2023 · control 56-AS-20230629154129

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint investigation into the allegation listed above. LPA met with Care Coordinator, Araceli Soto to discuss elements of the complaint. During today's visit, LPA interviewed staff and residents, collected pertinent documents and completed a walk through of the resident's room. It is alleged that staff are not meeting resident's dietary needs. Staff interviews revealed that the resident eats all of her meals. Facility staff do not maintain weight records for residents. Record reviews revealed that the resident's dietary needs are being met. Residents deny that they do not get enough food to eat. Residents also deny their dietary needs are not met. Based on information above, these allegations are 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 aRead the full finding— CDSS inspection report, August 31, 2023 · control 56-AS-20230825163400

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale unannounced to deliver the findings of the complaint investigation. LPA met with Araceli Soto, Care Coordinator to discuss elements of the complaint allegations. It is alleged that Resident is being physically attacked by another resident in care. Staff interviewed denied the incident happened. LPA observed resident notes dated 07/01/23 that state R1 was bit by R2. Based on LPA observation, the allegation resident is being physically attacked by another resident in care is substantiated. Substantiated— CDSS inspection report, August 28, 2023 · control 56-AS-20230727151227

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to unannounced to deliver the findings of the complaint investigation. LPA met with Care Coordinator Assistant, Gwen Galvan to discuss findings. It is alleged that the staff abandoned resident at a mental health facility. Staff interviews revealed that a resident in care began experiencing an increase in negative behaviors toward staff and residents. Medication Technicians and Administrative Staff worked within the resident's support system to make arrangements to get the resident psychiatric assistance. Included with arrangements was transportation of the resident. Record reviews indicated that the resident's admission to another facility was confirmed before the resident was transported out of the facility. Staff at the accepting facility were aware of the resident's incoming admission to their facility. Please see LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, August 23, 2023 · control 56-AS-20230622102617

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint allegation into the allegations listed above. LPA approached the front desk, introduced self and stated purpose of the visit. Staff informed LPA that the Administrator and Care Coordinator are out for the day, but Care Coordinator Assistant, Gwen Galvan, (GG) offered to assist LPA. LPA and GG met and discussed the complaint. Today's visit included a walk through of the facility, staff and resident interviews, file review and collection of pertinent documents. It is alleged that staff is allowing resident to leave the facility without staff supervision. LPA interviewed staff and resident. Interviews revealed that R1 can leave the facility on their own. LPA conducted a file review and observed the resident's most recent Physician’s Report which indicates the resident can leave the facility without supervision. UnsubstantiatedRead the full finding— CDSS inspection report, August 22, 2023 · control 56-AS-20230818143744

Licesning Program Analyst, Amber Coleman arrived at the Montclair Royale Senior Living Facility to unnannounced to deliver the findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Administrator, AnnaMarie Santos, to discuss elements of the complaint. It is alleged that facility staff did not insure residents had hot water to shower. During staff interviews, LPA learned that the facility's boiler stopped working properly between 1/30/23 and 2/3/23. Maintenance staff examined the boiler and determined a part was required in order to fix it. Receipts from Ferguson Enterprises indicate, new part was ordered on 2/4/23, picked up on 2/5/23 and the facility boiler was fixed by 2/6/23 restoring hot water to the facility. It is alleged that the resident's room is in disrepair. Resident and staff members statements were consistent. The resident's room had a water leak in the ceiling. LPA also observed evidence of a water leak on the resident'Read the full finding— CDSS inspection report, August 22, 2023 · control 56-AS-20230206124429

Licensing Program Analyst, Amber Coleman (LPA) arrived to the Montclair Royale Senior Living unannounced to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator Assistant, Gwen Galvan to discuss elements of the allegations.During today's visit, LPA conducted staff and resident interviews, a walk through of the facility and collection of pertinent documents. It is alleged that staff did not prevent resident from being a victim by an unknown perpetrator. During interview, with R1, it was reported that R1 put a large sum of cash in her nightstand; approximatley, $700. This was reported to staff who contacted Law Enforcement for assistance. Staff interviews revealed that this incident occured in December 2022. The Montclair Police Department was contacted and made a visit to the facility. Police determined there was not enough evidence to make a report or pursue the theft. Please see LIC9099Read the full finding— CDSS inspection report, August 22, 2023 · control 56-AS-20230818153950

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to initiate a complaint investigation into the allegations listed above. LPA signed in and met with Care Coordinator, Araceli Soto. It is alleged that staff did not inform resident's responsible party of incident(s). Interview with staff revealed that two (2) incidents occurred between residents and responsible party was informed. LPA observed an incident report with a notation that responsible party was notified. Interview with responsible party denies receiving any notification about the incidents. Interviews with staff, resident and responsible party revealed conflicting information regarding if incident was reported to responsible party. Due to conflicting interviews, the allegation, staff did not inform resident's responsible party of incident(s) is unsubstantiated. UnsubstantiatedRead the full finding— CDSS inspection report, July 31, 2023 · control 56-AS-20230727151227

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Care Coordinator Araceli Soto. The investigation consisted of resident interviews, staff interviews, document review, and a facility tour. For allegation, Staff did not properly assist resident with their medication: It was alleged that two (2) residents (R1 & R2) did not get assistance with refilling their medication in a timely manner. Interviews with staff and document review revealed that there was an uncontrollable shipping delay with the shipping partner that the pharmacy uses to deliver medications. The pharmacy and the facility worked together to resolve the issue by using an alternative shipping company. UnsubstantiatedRead the full finding— CDSS inspection report, July 28, 2023 · control 56-AS-20221228154401

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to the facility to continue the complaint investigation and deliver findings on the above allegation. LPA met with assistant care coordinator Gwen Galvan who was informed of the purpose of today’s visit. Administrator Annamarie Soto arrived during the visit. The investigation consisted of resident interviews, LPA observations, and records review. It is alleged that Resident (R1) fell sustaining an injury while in care. CCL Regional office received an incident report that on 4/6/2023 R1 was sent to the hospital after being found with a skin tear from a suspected fall. LPA reviewed records stating that R1 was admitted to this facility on 9/16/22, does not need a 1-1 assistance, and ambulates independently without any physical assistance. LPA did not find any other incidents relating to a fall. LPA attempted to interview R1 but was unsuccessuful due to R1's cognitive impairment. However, LPA observed R1 sRead the full finding— CDSS inspection report, July 24, 2023 · control 56-AS-20230412104719

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to the facility to continue the complaint investigation and deliver findings on the above allegation. LPA met with care coordinator assistant Gwen Galvan who was informed of the purpose of today’s visit. Administrator Annamarie Soto arrived during the visit. The investigation consisted of staff interviews and records review. LPA was unable to speak with Resident (R1). It is alleged that Staff did not inform resident's (R1) authorized person of changes to resident's care or placement. LPA reviewed records showing that R1 previously resided at this facility from 10/05/2021 through 06/11/2023. Records reviewed show that R1 was under the care of the San Bernardino County Office of the Public Guardian (PG). Interview with staff reveal that the facility contacted the PG as early as 06/09/23 due to R1 attempting to self admit at a medical facility for experiencing hallucinations. LPA reviewed records from 06/Read the full finding— CDSS inspection report, July 24, 2023 · control 56-AS-20230623110652

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint investigation into the allegation listed above. LPA introduced self to staff, singed in visitor's log and stated the purpose of the visit. LPA met with Administrative Staff Member, Gwen Galvan, who informed LPA Care Coordinator, Araceli Soto and Administrator, AnnaMarie Santos-Tabila were out of the facility. During the interaction, Gwen Galvan informed Care Coordinator, of LPA's visit. During the visit, LPA met with staff and residents for interviews, collected pertinent documents, completed a walk through of the facility and delivered findings. Staff interviews and correspondence revealed that there was an attempt to evict a resident in care in 3 days; due to an increase in aggressive behaviors. Documentation collected revealed that the request to evict the resident in 3 days was not approved by the Community Care Licensing Office. Documentation fRead the full finding— CDSS inspection report, July 17, 2023 · control 56-AS-20230711095633

Licensing Program Analyst, Amber Coleman, (LPA) arrived to the Montclair Royale Senior Living Facility unannounced to deliver findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto and stated purpose of the visit. The investigation included staff, resident, and witness interviews, collection and review of resident files/documents. It is alleged that staff failed to provide a safe environment for the resident. Witness and Resident (R1) interviews revealed that the resident moved in and was placed with another Resident (R2). The two (2) residents shared a conflict with one another that resulted in a physical altercation. Facility staff separated the two residents by finding another room for R1. The Police were called. Police determined that there was no action to be taken because both residents involved had assaulted one another. Staff interviews were consistent with the witness and R1’s interviews. AccordRead the full finding— CDSS inspection report, June 28, 2023 · control 56-AS-20230511112540

During staff interviews, LPA learned that Resident #1, (R1) moved into the facility on August 25th, 2022. R1 and his family worked together to complete an Admissions Packet which included the facility's House Rules and a Pre Appraisal form. The documents were signed on 8/25/22 which signified that the house rules were understood and would be followed by R1. The Pre-Appraisal form indicated that R1 entered the facility with no belongings of substantial value, this document was also signed on 8/25/22. It is alleged that the facility did not safeguard the resident's personal property. LPA observed an Incident report dated on 3/15/23 which indicated R1 suffered a medical emergency and had to be taken to the Hospital. When Medical Staff arrived, they had a hard time getting to R1 due to the amount of clutter in the room. When R1 returned to the facility from the hospital, he alleged the facility had stolen his property. During interviews with staff and R1, LPA learned that the items removedRead the full finding— CDSS inspection report, May 31, 2023 · control 56-AS-20230330093256

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto to discuss the complaint and allegations. The investigation consisted of staff and resident interviews, record reviews and observations of the kitchen and food service. During staff interviews, LPA learned that dietary needs are discussed during the admissions process. Their dietary needs are also documented. If the dietary needs should change, the doctor sends orders directly to the facility. Doctor orders for dietary needs are given to the Dietary Staff who keeps records of these changes. Kitchen staff print a daily list of residents who require a certain diet. Kitchen staff report that meals are always prepared and provided to residents in care. Often times, resident may not like one item or another. It is a resideRead the full finding— CDSS inspection report, May 30, 2023 · control 56-AS-20230526084728

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to deliver findings of complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto. It is alleged that staff did not ensure that the resident was accorded privacy while care was being provided. Interviews with residents revealed that the blinds from their two room windows were missing. The resident's room is located on the bottom floor adjacent to the entry way to the facility patio. When it becomes dark out, the room is illuminated, allowing a view into insde the resident room. This was reported to staff on several occasions, but was never addressed. On 4/14/23, at approximately 4pm, LPA observed the window blinds missing. Staff interviews revealed, that the facility does have a work order system in place. Residents will verbally report to maintenance staff what needs to be fixRead the full finding— CDSS inspection report, May 30, 2023 · control 56-AS-20230413141951

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to continue the investigation of and deliver findings on the above mentioned allegations. LPA met with care coordinator Araceli Soto who was informed of the reason for today's visit. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1 and 2: Residents elope due to facility door lock broken AND Facility is in disrepair. The Department received a special incident report of resident elopement. Staff interview revealed that the memory care door lock was broken, allowing memory care residents to leave the unit. Staff further stated that care staff assigned to temporarily guard the door quit and walked off in the middle of their shift. This allegation is substantiated. Allegation 3: Food service staff serve expired food and uncooked food. Witness interviews confirmed that food items were expired and tossed out. Interviews reveal thRead the full finding— CDSS inspection report, December 7, 2022 · control 56-AS-20220602102400

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to continue the investigation of and deliver findings on the above mentioned allegations. LPA met with care coordinator Araceli Soto who was informed of the reason for today's visit. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1: Uncleared staff working at the facility. LPA reviewed records and found Staff (S1) was associated to the facility for a time. Interview with staff confirms that S1 was employed by this facility and terminated when the facility received the exemption denial letter from CBMP. Allegation 2: Staff have not received required training. LPA received and reviewed facility med tech schedule and found Staff (S2) on rotation. Staff interview revealed that S2 has not received their full medication training and is shadowing current med techs. Records show that S2 is assigned a schedule and witness interviewRead the full finding— CDSS inspection report, December 7, 2022 · control 56-AS-20220329095154

Licensing Program Analysts (LPA) Melody Brown and Victoria Chitgian met with Administrator Annamarie Santos-Tabila at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 10/27/2022 at 10:30 AM to deliver findings for the allegation listed above. LPAs Brown and Chitgian explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and review of pertinent documentations. Through the information gathered during the investigation, it was confirmed by documents review and interviews that Communications to the facility are not being answered promptly. It was alleged that on 07/11/2022, the facility would not answer calls from hospital staff to report Resident 1 (R1) status. LPA Brown initiated the investigation on 07/15/2022. Interviews with staffs indicated knowledge of the implemented Facility Directive to Night/NOC Shift Medical Technicians (Medtech) that *** Continuation on LIC9099 *** SubstantiatedRead the full finding— CDSS inspection report, October 27, 2022 · control 56-AS-20220712101447

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Mikaila Tonan, receptionist. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1: Staff is not assisting resident with hygiene needs. Interviews reveal that Resident 1 (R1) is ambulatory and capable of self-care with minimal assistance. Allegation 2: Facility is not safeguarding resident's belongings. Based on observations and interviews, LPA was able to confirm that it is the facility’s policy to have residents label their belongings. Allegation 3: Staff are not ensuring resident has clean clothes. Interviews reveal that R1 always has clean clothes available however R1 may need to change clothes after meals. Allegation 4: Resident's room does not have adequate lighting. LPA was unable to find corroborating evidence relating to this allegation. Allegation 5: Resident'Read the full finding— CDSS inspection report, May 6, 2022 · control 18-AS-20220105101235

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Mikaila Tonan, receptionist. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1: Staff did not administer resident's medication as prescribed. The investigation revealed that while Resident 1 (R1) was being given medication, R1 will sometimes not take the medication. Also, it was revealed that R1 is ambulatory and self responsible. Allegation 2: Staff did not provide adequate food service. The investigation revealed that R1 does not have a special diet. This facility provides a modified menu for residents with dietary restrictions. Allegation 3: Resident was not provided clean linen. Interviews reveal that R1 had purchased their own linens. Also, LPA verified that the facility has a supply of clean linen labeled with the facility’s name and residents are also able toRead the full finding— CDSS inspection report, May 6, 2022 · control 56-AS-20220318083750

Licensing Program Analysts (LPAs) Ryan Gardner and Anna Bueno arrived at the facility unannounced to commence a complaint investigation and deliver the findings for the complaint allegation. LPAs met with Care Coordinator, Araceli Soto. After interviews, record review, and gathering evidence, it was determined that the residents' money is not managed by the facility. Resident is on an Assisted Living Wavier Program that helps cover the residents monthly rent. The facility does not manage personal money for residents. Thus, the allegation was deemed to be UNFOUNDED. LPAs determined that the allegation, "Facility mismanaging residents' funds" was deemed to be UNFOUNDED. A finding of UNFOUNDED means that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was given to Araceli Soto. LPA did not observe any violations of Title 22 during this visit. UnfoundedRead the full finding— CDSS inspection report, February 28, 2022 · control 18-AS-20220222112449

Licensing Program Analysts (LPAs) Anna Bueno and Rohit Lama conducted an unannounced visit to this facility to investigate and deliver findings on the above allegations. LPAs met with care coordinator, Araceli Soto and advised them of the purpose of today's visit. The investigation consisted of interviews and review of pertinent documents. Allegation 1: Administrator does not respond to resident's representative. Interviews revealed that resident 1 (R1) is able to communicate their needs to staff. LPAs observed R1 speaking to several staff. Allegation 2: Staff do not assist resident with incontinence needs. Interviews revealed that the facility changes diapers every two hours. LPAs interviews and observations reveal that R1 needs moderate assistance toileting while resident 2 (R2) bathing are provided by another vendor. Allegation 3: Residents room is malodorous. Interviews show that resident rooms are cleaned daily and have scheduled thorough cleaning weekly. R1 stated that they ask hRead the full finding— CDSS inspection report, December 6, 2021 · control 18-AS-20211129084328