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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:49:04 PM

Document Has Been Signed on 08/06/2024 05:49 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: 10DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Mirriam Paras/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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On this day, 8/06/24, while at the facility investigating a complaint (Complaint Control # 15-AS-20240731080957), Licensing Program Analyst (LPA) Delmundo observed the following:
1. Staff (S1) is not fingerprinted and cleared.
2. Portable bed in resident's room and foldable bed in the closet in this resident's room. LPA verified, and according to the administrator, the beds are that of the staff. LPA also observed staff's personal stuff in the same room.

Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Civil penalties were assessed on this same day for the following:
1. Deficiency section 87355(e)(1) - $200.00 and will continue for $100.00/day until corrected.
2. Deficiency section 87307(a) - $250.00 for repeat violation within 12-month period.
Failure to submit proof of corrections may result in additional civil penalties.

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

Exit interview conducted. Appeal Rights, LIC421IM and LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form 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
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 08/06/2024 05:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/06/2024 at 04:51 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: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance ............
-This requirement is not met as evidenced by:
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Staff left while LPA was at the facility.

Administrator to have the staff fingerprinted and submit proof by 8/07/24. In addition, administrator not to allow S1 to work until cleared and associated.
$200.00 civil penalty assessed.
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-Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care.

Civil penalty assessed.
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Type B
08/20/2024
Section Cited
CCR87307(a)

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87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, ........
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Staff removed the items.

In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/20/24.

$250.00 civil penalty is assessed.
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-This requirement is not met as evidenced by:
-Based on observation and interviews, the licensee did not comply with the section above in making the resident's room storage for staff's belongings/beds. This is a repeat violation within 12-month period. The first citation was issued 3/08/24.
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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: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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