361881048-4-29-2026-56-AS-KCLS-DTMRUC-20260430131942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881048
Report Date: 04/29/2026
Date Signed: 04/29/2026 11:09:16 AM

Unsubstantiated

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
08/19/2025 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250819104741

FACILITY NAME:	AQUA RIDGE OF MONTCLAIR		FACILITY NUMBER:	361881048
ADMINISTRATOR:	MONIQUE DEL JUNCO		FACILITY TYPE:	740
ADDRESS:	9631 MONTE VISTA AVE		TELEPHONE:	(909) 483-2782
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	150	CENSUS: 85	DATE:	04/29/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Monique Del Junco, Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Questionable Death.
Neglect/Lack of Care and Supervision -Resident developed pressure injury while in care due to staff neglect.
Facility charged resident for a service they did not receive.

INVESTIGATION FINDINGS:

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On 04/29/2026 at 9:15 AM, Licensing Program Analyst (LPA), Eldin Serrano, visited the facility to deliver the investigative findings for the above allegations. LPA Serrano identified himself and discussed the purpose of the visit with Executive Director Monique Del Junco.

The Department investigated the above allegations, which included a review of facility records, medical documentation, and interviews with relevant parties.

Allegation: Questionable Death
It was alleged that facility staff mishandled Resident #1 (R1’s) medical emergency on 08/09/2025 after he reported feeling a pill stuck in his throat. It was alleged that staff provided inappropriate care, failed to recognize the severity of the condition, and delayed calling 911, resulting in the resident’s death.
Records reviewed, including facility files and medical documentation, indicate that staff followed R1’s treatment orders and monitored their condition. Documentation shows that staff remained with R1, observed changes in condition, and contacted 911 in a timely manner. Phone records reviewed during the investigation corroborate that 911 was called and that the resident’s family was contacted to provide updates and to clarify Physician Orders for Life-Sustaining Treatment prior to initiating life-saving measures. The coroner’s report identified the cause of death as hypoxemic respiratory failure, chronic atrial fibrillation, and ischemic stroke, which are consistent with the resident’s documented medical history. The coroner’s findings, as well as reports from paramedics and hospital personnel, indicated no evidence of abuse, neglect, malnourishment, or suspicious circumstances. Interviews conducted with staff were consistent with documentation reviewed.

Based on the information obtained, there is insufficient evidence to support that staff delayed emergency response or failed to provide appropriate care. Therefore, the allegation is Unsubstantiated.
******conitnuation on LIC9099C******

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20250819104741

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: 04/29/2026

NARRATIVE

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Allegation: Neglect/Lack of Care and Supervision – Resident developed a pressure injury while in care due to staff neglect

It was alleged that resident #1 (R1) developed a pressure injury while in care due to staff neglect. Records reviewed, including facility documentation and medical records, indicate that R1 had a history of medical conditions that placed R1 at high risk for skin breakdown. Documentation shows that the pressure injury was being treated by facility staff, as well as outside providers including home health nurses and wound care specialists. Medical records further indicate that the wound was actively managed by the facility in coordination with Kaiser Permanente. The home health agency reported no concerns regarding neglect during their visits. The coroner’s report noted no evidence of abuse, neglect, malnourishment, or suspicious circumstances.

Documentation shows that when the pressure injury did not improve, the facility arranged for hospital evaluation and placement in a skilled nursing facility. Interviews conducted with residents did not reveal concerns related to neglect or abuse. Residents reported that staff responded to requests for assistance in a timely manner. Therefore, the allegation is Unsubstantiated.

Allegation: Facility charged resident for a service they did not receive.

Based on the interviews conducted with the residents and staff, it was confirmed that the facility does not charge the residents for any services not received, therefore the allegation is unsubstantiated.

Based on the evidence obtained during the Department’s investigation, there is insufficient evidence to support the allegations. Although the allegations may have occurred or may be valid, there is not a preponderance of evidence to establish that a violation occurred. Therefore, the allegations are deemed Unsubstantiated.

An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and provided to executive director Monique Del Junco.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC9099 (FAS) - (06/04)

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