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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 04/26/2024
Date Signed: 04/26/2024 07:15:11 PM

Document Has Been Signed on 04/26/2024 07:15 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/
DIRECTOR:		MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:22107 MONTGOMERY STREETTELEPHONE:
(510) 889-8556
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 15DATE:
04/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Mirriam Paras/AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 3/08/24. LPA met with Mirriam Paras, administrator, and informed the reason for visit.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff. Residents' medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

LPA obtained updated/current copies of the following documents:
1. LIC308 Designation of Facility Responsibility
2. LIC610E Emergency Disaster Plan (9 pages)
3. Proof of $3M liability Insurance coverage
4. Proof of Control of Property/Lease Agreement (expiration: 1/31/25)

LPA observed the following:
-at 1:35 p.m., S1 has no First Aid certificate on file (expired 6/2017).
-at 1:45 p.m to 2:35 p.m., staff (S2, S3 and S5) do not have First Aid certificate. Required training for 2023 for postural support/restricted health condition/hospice care and medication training incomplete - only 2 hours medication, 2 hours postural support on file.
-at 2:40 p.m., staff (S4) no training record on file for 2019, 2020, 2021. No First Aid certificate on file.
-at 2:45 p.m., residents' (R1, R2, R3) LIC602A Physician's Report over a year old (on file dated 8/05/21 for R1, 2/20/23 for R2, 7/08/22 for R3).

.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/26/2024
NARRATIVE
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Page 2

-no doctor's order on file for R1, R3 and R5's half bed rails.
-residents (R3 and R4) who are not able to exit on their own due to medical diagnosis/condition (non-ambulatory) are in bedrooms not fire cleared for non-ambulatory.
-at 3:40 p.m., resident (R5) has no medical assessment (LIC602A) on file.
-at 5:00 p.m., no doctor's order on file for the following: R1's 10 medications; R2's 5 medications; 2 of R5's medications.

Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87705(c)(1) and will continue for $100.00/day until corrected. Any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/26/2024 07:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 05:45 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(1)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, interviews and observation, the licensee did not comply with the section cited above in 2 residents (R3 and R4) in bedrooms not fire cleared for non-ambulatory which poses an immediate safety and/or personal rights risks to persons in care.
A $500.00 civil penalty is assessed.
POC Due Date: 04/27/2024
Plan of Correction
1
2
3
4
Administrator contacted the residents' responsible persons and stated she will have the residents move out. Proof to be submitted by 4/27/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
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4
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/26/2024 07:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 05:45 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in staff (S2, S3, S4, S5) not having the complete required number of hours of annual training which poses potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
4
Administrator to have the staff complete the required training and submit self-certification by 5/10/24.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in R5 not having medical assessment (LIC602A) which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
4
Corrected.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/26/2024 07:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 05:45 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews and record review, the licensee did not comply with the section cited above in R3 and R4's ambulatory status not consistent with mental/medical condition (non-ambulatory) which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
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Administrator to obtain updated LIC602A and submit copies by 5/10/24
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in not having doctor's order for R1, R3 and R5's bedrails which pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
4
Administrator to obtain doctor's order and submit copies by 5/10/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/26/2024 07:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 06:17 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)
87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R1,R2 & R3’s LIC602A Physician's
Reports over a year old which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
4
Administrator to have the residents medically assessed and submit self-certification by 5/10/24 that LIC602As are obtained.
Type B
Section Cited
CCR
87411(c)
87411 Personnel Requirements - General
(c)…..(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S1's first aid certificate expired and S2, S3, S4 & S5 not having first aid certificates on file which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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2
3
4
Administrator to have the staff register and complete the training and submit copies of certificates by 5/10/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/26/2024 07:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 06:24 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in not having doctor's order which pose an immediate health, and/or personal rights risks to persons in care for the following: R`1's 10 medications; R2's 5 medications; 2 of R5's medications;
POC Due Date: 04/27/2024
Plan of Correction
1
2
3
4
Administrator stated she'll obtain doctor's orders. Copies to be submiitted by 4/27/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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