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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 04/19/2024
Date Signed: 04/19/2024 07:14:20 PM

Substantiated


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
04/12/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240412115612
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: 14DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Mirriam Paras/AdministratorTIME COMPLETED:
07:15 PM
ALLEGATION(S):
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Staff are not meeting resident's (R1) medical needs.
INVESTIGATION FINDINGS:
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At 11:35 a.m., on this day, 4/19/24, Licensing Program Analyst (LPA Delmundo arrived unannounced to investigate the above allegation. LPA met with Mirriam Paras, administrator, and informed the reason for visit.

It was alleged that staff do not check R1's blood pressure nor give eye drops. It was further alleged that R1 ran out of fungus cream.

During investigation, LPA reviewed resident's file including but not limited to doctor's order of medications and Medication Administration Record (MAR). LPA interviewed R1, 4 staff (S1, S2, S3 and S4) and administrator.

R1 stated staff do not check R1's blood pressure (BP), do not give her eye drops, and her fungus cream run out.
.......continued 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
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 6
Control Number 15-AS-20240412115612
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: 04/19/2024
NARRATIVE
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Although 3 of the 4 staff interviewed stated they check R1's BP when requested and put cream on R1's forehead, ears and on the back of R1's ears, the fungus cream run out which was confirmed by LPA with the administrator. MAR showed R1 is given eye drops. Review of records showed R1 has doctor's order for other cream for the scalp in August 2023, however, this particular cream was never refilled, and administrator admitted to not following-up with the doctor.

Based on records review and interviews, the preponderance of evidence is met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20240412115612
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility......by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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One of the cream is delivered on 4/18/24.

Administrator to check with the doctor if the other cream is still needed and submit proof by 4/20/24.
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-This requirement is not met as evidenced by:

-Based on review of records and interviews, the licensee did not comply with the section above when R1's cream run out and did not obtain nor follow-up with the doctor for the other cream.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/12/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240412115612

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: 14DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Mirriam Paras/AdministratorTIME COMPLETED:
07:15 PM
ALLEGATION(S):
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-Staff handled resident in a rough manner.
-Staff did not ensure the bathroom had hot water.
-Staff are not meeting residents needs.
-Staff did not prevent resident from engaging in inappropriate behaviors.
-Staff made inappropriate comments towards resident.
-Staff did not ensure facility furniture was clean
-Facilty has bed bugs.
INVESTIGATION FINDINGS:
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At 10:45 am on this day, 4/19/24, Licensing Program Analyst (LPA Delmundo arrived unannounced to investigate the above allegations. LPA met with Mirriam Paras, and informed the reason for visit.

During investigation, LPA reviewed resident's file and obtained copies of documents. LPA conducted inspection, and interviewed 3 residents including R1, 4 staff (S1, S2, S3 and S4) and administrator.

Allegation: Staff (S1) handled resident (R1) in a rough manner.
Originally, R1 stated that a Mexican staff pulled R1's arm while in the shower because R1 asked the staff to wash R1's underarm. LPA interviewed R1 who stated it was staff (S1) who pulled her arm. LPA interviewed 4 staff who stated no staff handled R1 roughly. S1 denied pulling R1's arm. The other 2 residents interviewed stated no staff were rough on them. Administrator stated facility does not have Mexican staff on the day of alleged incident.
........continued 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240412115612
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: 04/19/2024
NARRATIVE
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Page 2

Allegation: Staff did not ensure the bathroom has hot water.
R1 stated the bathroom has no hot water. All 4 staff, administrator and 2 other residents interviewed stated the facility never run out of hot water. LPA tested the water temperature which was measured at 105.2 degrees Fahrenheit.

Allegation: Staff are not meeting residents needs.
R1 stated when R1 wet self and asked to be changed, staff told her she'll come back and it took more than 1 hour to be changed. R1 futher stated that the bedsheet was not changed. Staff (S3) stated that on the date of incident, she was assisting other resident in the bathroom and told R1 to wait. S3 stated she came back in less than 20 minutes and assisted R1 to the bathroom and changed her. All 4 staff stated they change residents bed covers daily. During today's inspection, LPA observed the residents beds clean and R1's bed with 2 chux on top of the bed cover. None of the beds were observed wet.

Allegation: -Staff did not prevent resident from engaging in inappropriate behaviors.
R1 stated resident R4 laughs and stares at her, R2 grabbed her water bottle and R3 stares at her. All 4 staff interviewed confirmed the incident happened but the other 2 residents who were laughing were talking to each other. Staff also confirmed R2 grabbed R1's water bottle; however the R4 and R2 have dementia and they separate and redirect residents when incidents happen.

Allegation: Staff made inappropriate comments towards resident.
R1 stated when R4 made fun of her and reported the incident to the administrator, the administrator told her to be nice and mind her own business. Although the administrator stated saying to R1, "Be nice, because the residents have dementia", she denied saying 'Mind your own business." All 4 staff and other 2 residents stated not hearing the administrator made inappropriate comments to R1. LPA was not able to obtain information from other 3 residents either due to residents' medical condition/diagnosis or resident was not at the facility.


.....continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20240412115612
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: 04/19/2024
NARRATIVE
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Page 3

Allegation: Staff did not ensure facility furniture was clean.
R1 stated chairs in the living room never get washed. LPA interviewed 4 staff who stated the chairs and couches in the living room have covers and at times get soiled when residents spill food or have accidents but when these happen, they removed the covers, and covers are washed. The administrator stated the couches have covers and when get soiled, one of the staff does the washing. LPA conducted inspection and didn't observed any of chairs and couches soiled or dirty.

Allegation: Facility has bed bugs.
R1 stated she has bed bugs in her body. LPA interviewed 4 staff and 2 residents who all stated not observing bed bugs. LPA conducted inspection and didn't observed any.

Based on information obtained and LPA unable to obtain information from 3 residents, all 7 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6