Community Care Licensing

Document Has Been Signed on 08/24/2021 03:24 PM - It Cannot Be Edited

FACILITY NAME:	MONTGOMERY SPRINGS MANOR		FACILITY NUMBER:	015601506
ADMINISTRATOR:	MIRRIAM PARAS		FACILITY TYPE:	740
ADDRESS:	22107 MONTGOMERY STREET		TELEPHONE:	(510) 889-8556
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 15		CENSUS: 12	DATE:	08/24/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Mirriam Paras		TIME COMPLETED:	03:30 PM

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

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable	1 2 3 4 5 6 7	By POC date Administrator agrees to review PIN 21-38-ASC and send a copy of self-certification document to CCL.
	8 9 10 11 12 13 14	accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the Licensee did not comply with the section cited above. PIN 21-38-ASC states "Well-fitting face mask is required in indoor settings (double mask or surgical mask recommended), unless an N95 respirator is required pursuant to Title 8 regulations." for all staff and Licensees. However, LPAs observed Administrator Mirriam Paras, S1, S2, and S3 in facility without a mask in common areas which which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 08/31/2021 Section Cited CCR87555(a)	1 2 3 4 5 6 7	87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food	1 2 3 4 5 6 7	Administrator agrees to dispose all expired and moldy food and send self-certification to CCL by POC date.
	8 9 10 11 12 13 14	and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. Based on observation the licensee did not comply with the section cited above. LPAs observed moldy cantaloupe in cabinet which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021