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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 06:43:43 PM

Document Has Been Signed on 04/26/2024 06:43 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: 14DATE:
04/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Mirriam Paras/Adminisrator TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Mirriam Paras, administrator, and informed the reason for visit.

On 3/08/24, LPA issued citations for the following deficiencies with POCs to be submitted by 3/09/24. On 3/09/24, the administrator submitted the LIC9098 Proof of Correction form, however, the POCs submitted were either missing or the in-service training do not pertain to the deficiencies cited. LPA informed the administrator about these on 4/17/24 and requested to submit the POCs before the end of the day that day, but the POCs were not submitted up to this date, 4/26/24:
1. Section 87202(a) – picture showing the storage on the 2nd floor is converted back to it’s original use.
2. Section 87309(d)(6) - in-service pertaining to the cited deficiency is missing. The in-service training submitted is not related to the cited deficiency.
3. Section 87309(a) - in-service pertaining to the cited deficiency is missing. The in-service submitted is also not related to the cited deficiency.

On this day, 4/26/24, the above deficiencies are re-cited. On this same day, LPA toured the facility with the administrator. LPA observed the storage on the 2nd floor is converted back to it's original use.

Deficiencies and proof of corrections were discussed with the administrator. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

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: 04/26/2024
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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Document Has Been Signed on 04/26/2024 06:43 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 12:34 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2024
Section Cited
CCR
87202a

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87202(a) Alll facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshall........

-This requirement is not met as evidenced by:
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Corrected.
LPA observed the storage is converted back to it's original use.
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-Based on observation, the licensee did not comply with the section cited above in converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care.
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Type B
04/27/2024
Section Cited
CCR87307(d)(6)

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8730787307 Personal Accommodations and Services: (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

-This requirement is not met as evidenced by:
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Administrator to in-service the staff, and submit proof by 4/27/24.
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-Based on observation, the licensee did not comply with the section cited above in stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights 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: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: 2 of 3
Document Has Been Signed on 04/26/2024 06:43 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/26/2024 at 12:41 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2024
Section Cited
CCR
87309(a)

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section cited above in
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Administrator to in-service the staff, and submit training topic with attendees signatures by 4/27/24.
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.... the following: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risks 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: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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