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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 09/04/2024
Date Signed: 09/04/2024 08:53:28 PM

Document Has Been Signed on 09/04/2024 08:53 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: 3DATE:
09/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Mirriam Paras/Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, September 4, 2024, while at the facility investigating a complaint (Complaint Control # 15-AS-20240830112641), Licensing Program Analyst (LPA) Delmundo observed the following:
1. Staff (S1) is not fingerprinted and cleared.
2. Flies flying around the residents' rooms, kitchen area, bathroom and living room.
3. Lavatory in the common bathroom not properly draining and cabinet in this bathroom in disrepair.
4. Inside of the refrigerator untidy.

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) - $100.00 and will continue for $100.00/day until corrected.
2. Deficiency section 87303(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: 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2024 08:53 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/04/2024 at 07:47 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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
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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Administrator stated she'll have the staff fingerprinted. Proof by 9/05/24. In addition, administrator not to allow S1 to work until cleared and associated.

$100.00 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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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: 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2024 08:53 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/04/2024 at 07:54 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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by
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Staff cleaned the refrigerators while LPA was at the facility.
In addition, administrator to do the following and submit proof by 9/18/24:
1. Have the bathroom cabinet repaired.
2. Have the lavatory unclogged.
3. Eradicate the flies and install door mesh.
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-Based on observation, the licensee did not comply with the section above in the following which pose a potential health and/or personal rights risks to persons in care: untidy refrigerators; bathroom cabinet in disrepair; clogged lavatory; flies.
This is a repeat violation within 12 month.
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A $250.00 civil penalty is assessed.

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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: 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


LIC809 (FAS) - (06/04)
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