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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 09/04/2024
Date Signed: 09/04/2024 08:55:12 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
08/30/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240830112641
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: 13DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mirriam Paras/Administrator TIME COMPLETED:
09:00 PM
ALLEGATION(S):
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Staff spoke to resident in an inappropriate manner.

INVESTIGATION FINDINGS:
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At 1:15 pm on this day, September 4, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Joseph Michael Madarang. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM), and informed the reason for visit. ADM arrived at around 3:10 pm.

During the course of investigation, LPA reviewed residents' records and obtained copy of LIC602A Physician's Report and interviewed staff (S1, S2, S3, S4) and ADM.

Allegation: Staff spoke to resident in an appropriate manner.
It was alleged that staff (S1) told R1 that R1 is heavy.
S1 stated she was assisting R1 and asked R1 to assist/help out in getting up from the chair and denied telling R1 she's heavy.
.......continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 5
Control Number 15-AS-20240830112641
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: 09/04/2024
NARRATIVE
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Page 2

One of the staff stated not working on the day the incident happened while the other one indicated not working on the same shift S1 worked. One of the four staff stated R1 told her about S1 telling R1 she's heavy. ADM stated S1 told her that she (S1) told R1 to help out in getting up from the bathing chair because she's heavy.

Based in interviews conducted, the preponderance of evidence has been met, therefore the allegation is found to be substantiated.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation within 12 month of section 1569.269(a)(1). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency, plan and proof of correction, and civil penalty were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC421FC 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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240830112641
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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
HSC
1569.269(a)(1)
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 ยง1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
-This requirement is not met as evidenced by
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Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/18/24.

A $250.00 civil penalty is assessed.
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-Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care.
This is a repeat violation. The first citation was issued on 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/30/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240830112641

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: 13DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mirriam Paras/Administrator TIME COMPLETED:
09:00 PM
ALLEGATION(S):
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-Staff do not answer to resident's request.

-Staff does not ensure resident is accorded privacy.

-Staff does not provide adequate food service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA called and spoke with Mirriam Paras, administrator (ADM), and informed the reason for visit. ADM arrived at around 3:10 pm.

During the course of investigation, LPA reviewed residents' records and obtained copies including but not limited to the following: LIC602A Physician's Report; doctor's order of medications. LPA interviewed residents (R1, R2, R3) and staff (S1, S2, S3, S4) and ADM, and conducted inspection.


....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 5
Control Number 15-AS-20240830112641
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: 09/04/2024
NARRATIVE
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Page 2

Allegation: Staff do not answer resident's (R1) request.
R1 indicated she requested the staff to move the wheelchair away from the door and staff did not answer the request. All the staff interviewed indicated not observing wheelchair blocking the door nor R1 requesting to remove the wheelchair. R2 and R3 stated not observing a wheelchair blocking the door.
Allegation: Staff does not ensure resident (R1) is accorded privacy.
R1 indicated she needed to use the bathroom and was not accorded privacy. One of the staff interviewed stated she was to give R1 eye drops and looked for R1 by calling her who was at the time was in the bathroom. The other staff indicated there are times when R2 will knock when R1 is in the bathroom to check first if someone is inside and that there's another toilet but these 2 residents prefer to use the big bathroom. The other residents interviewed stated being accorded privacy and staff are respectful.

Allegation: Staff does not provide adequate food service.
It was alleged that R1 had diarrhea for several days and was told by a nurse that it's due to the food.
R1 was interviewed who stated she's having diarrhea for days and her doctor told her it's because of the abscess tooth and that she was referred to the dentist. Copy of documents obtained by LPA showed R1 is prescribed anti-biotics. The other 2 residents interviewed stated food serve is always good. All the staff interviewed indicated not serving stale food. LPA conducted inspection and didn't observe any expired food.

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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5