Incident investigation·August 17, 2023

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 8/15/23. The incident involves a resident in care who gained access to and consumed perfume. LPA met with Administrative Staff, Gwen Galvan. LPA introduced self and stated purpose of the visit. Today's visit consisted of collection of pertinent documents, a walk through the resident's floor and assigned room and staff interviews. LPA observed three to four staff members on the floor at the time of the visit. LPA asked staff to show LPA were the chemicals and toxins are kept to inspect the area. Staff escorted LPA to the floor's dining area where two white cabinets are housed. The cabinets stood approximately 4 feet tall. Each cabinet has double doors. They each have the equipment necessary to secure the cabinet. At approximately 1:25pm, LPA observed the two cabinets and observed that while the doors were shut, the locks were not engaged, making it accessible to residents in care. Based on observations and interviews, one deficiency will be cited per Title 22, Division 6, of the California Code of Regulations. An exit interview, was conducted where this report was discussed, reviewed and provided to Facility Representative.