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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:46:06 PM

Unsubstantiated


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
07/31/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240731080957
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: 10DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mirriam Paras/AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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-Staff do not provide adequate food service to resident in care.

-Staff do not meet resident's dietary needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Mirriam Paras, administrator, and informed the reason for visit.

During the course of investigation, LPA reviewed residents' records and obtained copies including but not limited to the following: LIC602A Physician's Report, Pre-placement Appraisal, Hospital Visit Summaries, Pre-procedure Instructions. LPA interviewed residents (R1, R2, R3, R4 and R5) and staff (S1, S2 and administrator).

Allegation: Staff do not provide food service to resident in care.
It was alleged that on 7/30/24, when resident (R1) came back to the facility after an appointment, R1 was only given chicken broth and juice.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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 2
Control Number 15-AS-20240731080957
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: 08/06/2024
NARRATIVE
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R1 confirmed that staff gave R1 chicken broth and juice. The two staff interviewed stated that on 7/31/24, R1 had a procedure and there's instruction that R1 should not be given solid foods day before the procedure which LPA confirmed from the document obtained during investigation. The other staff was not able to provide information as this staff is new and was not working yet at the time of the said incident.

Allegation: Staff do not meet resident's dietary needs.
It was alleged that staff serve meat a lot and that R1 can not eat meat and staff does not offer substitute.

LPA observed during inspection that residents were served barbecued meat during lunch. R1 stated she ate the barbecue and is not on special diet. Review of records showed R1 is not on special diet nor on diet restrictions. Two of the staff stated R1 eats meat and there are times when R1 does not want to eat meat but is not on special diet. These 2 staff stated facility offers substitute.

The other four residents stated the food served is good. Three out of these 4 residents stated staff provides substitute if they don't want what is served.

Based on information gathered, the above 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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2