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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 06/13/2023
Date Signed: 06/13/2023 12:52:13 PM

Document Has Been Signed on 06/13/2023 12:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 7DATE:
06/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mirriam Paras, AdministratorTIME COMPLETED:
01:30 PM
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On 06/13/23 at 10:30 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving an incident report regarding 13 residents evacuated by staff and the fire department as a result of a fire hazard (smoke from stove wall) which occurred at the facility on 06/11/23. All residents and staff were temporarily transferred by staff to 3 different unlicensed facilities (2) in San Leandro CA and one (1) in Hayward CA. LPA explained the purpose of the visit with staff (S1, S2) and administrator (ADM).

During the health and safety checks at the three (3) unlicensed facilities, LPA observed a total of two (2) staff (S1, S2) and seven (7) residents (R1, R2, R3, R4, R5, R6, R7) relocated at 429 Linnel Avenue San Leandro, CA 94578 . LPA observed a total of three (3) residents (R8, R9, R10) relocated at 15997 Wellington Way San Leandro CA 95478 with one (1) staff (S3) providing care and supervision. LPA observed three (3) residents (R11, R12, R13) relocated at 2843 Sunnybank Lane Hayward CA 94541 with one (1) staff (S4) providing care and supervision.

LPA toured the three (3) unlicensed facilities with ADM including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care were observed safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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