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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:20:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210819111057
FACILITY NAME:MONTGOMERY SPRINGS MANORFACILITY NUMBER:
015601506
ADMINISTRATOR:MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:22107 MONTGOMERY STREETTELEPHONE:
(510) 889-8556
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 12DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Mirriam ParasTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility staff hit resident
INVESTIGATION FINDINGS:
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On 08/24/2021 at 8:50am Licensing Program Analysts (LPAs) Allison O'Hollaren (AO) and Jill Clancy-Czuleger arrived unannounced to conduct an initial complaint opening. LPAs met with Mirriam Paras and explained the purpose of the visit.

During the course of the investigation, LPAs interviewed 1 Administrator, 3 staff and 9 residents. Due to issues with language barriers, LPAs were unable to obtain information from 1 staff.

Based on interviews with 9 residents and 2 staff, 8 out of 9 residents stated to have never been hit by a staff and have never witnessed a staff hit a resident, and 2 of 2 staff stated to have never hit a resident, nor witnessed a staff hit a resident.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 2
Control Number 15-AS-20210819111057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506
VISIT DATE: 08/24/2021
NARRATIVE
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LPAs reviewed staff schedule, staff roster, resident roster, physician reports, and needs and services plans.

The Department has investigated these allegations and based upon interviews conducted and records reviewed, these allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation has occurred.

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2