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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881048
Report Date: 04/11/2025
Date Signed: 04/11/2025 01:28:58 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
04/25/2022 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20220425105127
FACILITY NAME:AQUA RIDGE OF MONTCLAIRFACILITY NUMBER:
361881048
ADMINISTRATOR:MONIQUE DEL JUNCOFACILITY TYPE:
740
ADDRESS:9631 MONTE VISTA AVETELEPHONE:
(909) 483-2782
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:115CENSUS: DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Monique Del JuncoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident's medication was not administered
INVESTIGATION FINDINGS:
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On 04/11/2025 at 1:00PM Licensing Program Analyst, Renese Howell-Small, (LPA) arrived at the Aqua Ridge of Montclair unannounced to deliver findings for the complaint investigation into the allegations listed above. LPA met with Administrator, Monique Del Junco; introduced self and stated purpose of the visit.
The investigation consisted of interviews and record review.

The fourth allegation alleged that the resident’s medication was not administered. The Medication Administration Record (MAR) dated 04/01/2022 indicates that the water pill was a PRN and to be given once daily as needed for edema. According to the MAR, the resident was given the water pill on 04/24/2022 to 04/27/2022 at 8:00AM.

The Physician’s Order indicates that the water pill was to be given every morning with a start date of 04/01/2022. The Administrator could not provide further documentation to support that the water pill was to be given as a PRN. Based upon interviews and record review, this allegation is SUBSTANTIATED
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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 5
Control Number 56-AS-20220425105127
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: AQUA RIDGE OF MONTCLAIR
FACILITY NUMBER: 361881048
VISIT DATE: 04/11/2025
NARRATIVE
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A SUBSTANTIATED complaint is defined as a violation has occurred and the preponderance of evidence has been met. An exit interview was conducted where a copy of this report along with appeal rights were provided to Administrator Monique Del Junco.

An exit interview was conducted where a copy of this report LIC9099, LIC9099D and Appeal Rights were discussed and provided to Administrator Monique Del Junco.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20220425105127
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: AQUA RIDGE OF MONTCLAIR
FACILITY NUMBER: 361881048
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2025
Section Cited
CCR
87465(d)(3
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87465 (d)(3) Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription... or nonprescription PRN medication, and is unable to...: (3) The date and time the PRN medication...
This requirement was not met as evidenced by:
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Licensee/Administrator will conduct training on medication and will submit proof to LPA by Plan of Correction due date.
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Based upon interview and record review, the Licensee/Administrator did not comply with the section cited above by not administering the water pill according to the physician’s orders, which posed an immediate risk to the health, safety and personal rights risk to resident 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/25/2022 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20220425105127

FACILITY NAME:AQUA RIDGE OF MONTCLAIRFACILITY NUMBER:
361881048
ADMINISTRATOR:MONIQUE DEL JUNCOFACILITY TYPE:
740
ADDRESS:9631 MONTE VISTA AVETELEPHONE:
(909) 483-2782
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:115CENSUS: DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Monique Del JuncoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
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3
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5
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9
Staff caused injury to resident.
Staff handled resident in a rough manner.
Resident sustained unexplained injury
INVESTIGATION FINDINGS:
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On 04/11/2025 at 1:00PM Licensing Program Analyst, Renese Howell-Small, (LPA) arrived at the Aqua Ridge of Montclair unannounced to deliver findings for the complaint investigation into the allegations listed above. LPA met with Administrator, Monique Del Junco; introduced self and stated purpose of the visit.
The investigation consisted of interviews and record review.

The first allegation alleged that staff caused injury to resident. The Nursing Assessment by the hospice agency dated 04/01/2022 states Resident 1 (R1) has frequent combative behaviors which may contribute to R1 sustaining injuries. An interview with the hospice nurse acknowledged that R1’s behaviors were combative and resistant which could contribute to R1 sustaining bruises or injuries. Staff 7 (S7) and Staff 8 (S8) confirmed that R1 displays combative behaviors during Activities of Daily Living (ADL). Eight (8) out of eleven (11) staff interviewed denied that staff caused injury to resident. Based upon interviews and record review, this allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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 5
Control Number 56-AS-20220425105127
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: AQUA RIDGE OF MONTCLAIR
FACILITY NUMBER: 361881048
VISIT DATE: 04/11/2025
NARRATIVE
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The second allegation alleged that staff handles resident in a rough manner. An interview conducted with the Administrator affirms that staff receive forty (40) hours of training in job related duties and will also shadow experienced trainers for on-the-job training. All care staff receive on-line training through Relias in various areas related to assisting residents with ADL, bathing, dressing and personal care.
On 04/28/22, an interview with the hospice nurse states that R1 was transferred in a safe manner. The hospice nurse stated that R1 was not on any meds that cause bruising, not on thinners." but the "bruises are not alarming" because R1 was combative. The hospice nurse did not know how R1 could have gotten the wound but did not think that it was suspicious. Lastly, R1 had a half rail on the bed, tears and bruising may be an ongoing thing with R1, as long as R1 was combative and resistant. Six (6) out of eleven (11) staff state that staff are well trained and worked with another staff when lifting or transferring R1. The Service Plan dated 01/13/22 indicates that R1 requires a two-person assist in transferring. Based on interviews and record review, this allegation is UNSUBSTANTIATED.


The third allegation is that the resident sustained an unexplained injury. The spouse of Resident 1 (R1) did not notice a skin tear on R1’s arm on 04/23/22. On 04/24/22 at 9AM, a family friend visited R1 and noticed the skin tear on R1’s left arm. An interview with the staff nurse (S4) confirmed that R1 was found on the morning of 04/25/22 with a skin tear and the family was notified. The hospice care notes indicate that on 04/26/22 a skin tear was observed on R1’s left arm. Five (5) out of eleven (11) staff denied causing injury to resident and did not observe the laceration when R1 went to bed the night of 04/23/22. Staff are trained in first aid, to document injuries and to notify both the family and a supervisor.

Based upon interviews and record review, these allegations are UNSUBSTANTIATED.


An UNSUBSTANTIATED complaint is defined as the allegation may have happened or is
valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where a copy of this report LIC9099 was discussed and provided to Administrator Monique Del Junco.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5