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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:14:06 PM

Document Has Been Signed on 02/23/2024 02:14 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: 13DATE:
02/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mirriam Paras, AdministratorTIME COMPLETED:
02:25 PM
NARRATIVE
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On 2/23/2024 at 1:20pm Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Mirriam Paras, Administrator, and explained the purpose of the visit.

While LPA L. Hall was conducting a complaint investigation (15-AS-20240221085509) on 2/23/2024. While touring facility LPA observed residents' beds did not have a mattress cover, top sheet, and some did not have a blanket. Staff stated beds are changed weekly or more often if necessary. LPA also observed two (2) slide latch locks on front entry/exit door. Staff 1 (S1) stated during interview that facility uses lock at night for a resident that wanders.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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Document Has Been Signed on 02/23/2024 02:14 PM - It Cannot Be Edited


Created By: Laura Hall On 02/23/2024 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2024
Section Cited
CCR
87307(3)(c)

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87307 (3) Equipment and supplies necessary for personal care... shall be readily available to each resident... C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads... The quantity shall be sufficient to permit changing at least once per week or more often when indicated...
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Administrator agreed to put appropriate linen on each resident bed and submit a self-certification that it has been completed to CCLD by POC date.
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This requirement was not met as evidence by:
Based on observation the Licensee did not comply with the section cited above in have appropriate linen on bed, which poses a potential health and safety risk to persons 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/23/2024 02:14 PM - It Cannot Be Edited


Created By: Laura Hall On 02/23/2024 at 01:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2024
Section Cited
CCR
87705(l)(6)

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87705 (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors... (6)Locked exterior doors or perimeter fences.. shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidence by:
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Administrator agreed to remove locks from entry/exit door and submit a photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited in using a lock on entry/exit door for wander residents, which poses an immediate health and safety risk to persons 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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