015601506-11-21-2024-15-AS-BFOG-DE934G-20250225165508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 11/21/2024
Date Signed: 11/21/2024 08:09:04 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
11/18/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20241118162509

FACILITY NAME:	MONTGOMERY SPRINGS MANOR		FACILITY NUMBER:	015601506
ADMINISTRATOR:	MIRRIAM PARAS		FACILITY TYPE:	740
ADDRESS:	22107 MONTGOMERY STREET		TELEPHONE:	(510) 889-8556
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	15	CENSUS: 13	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Mirriam Paras/Administrator		TIME COMPLETED:	08:10 PM

ALLEGATION(S):

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-Staff not treating resident with respect and dignity.
-Staff does not respond to resident's request in a timely manner.
-Staff does not provide resident a safe environment.
-Staff does not provide adequate food service to resident.
-Facility failed to maintain a comfortable room temperature.

INVESTIGATION FINDINGS:

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At 11:05 am, Licensing Program Analysts (LPAs) A. Delmundo and A. Gharachorloo arrived unannounced to investigate the above allegations. LPAs met with Mirriam Paras, administrator (ADM), 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; hospital After Visit Summary. LPAs also obtained copies of LIC9020 Register of Facility Clients/Residents and menu. LPAs conducted inspection and interviewed residents (R1, R2, R3, R4, R5, R6, R7, R8), staff (S1, S2, S3, ADM) and witness (W1).

Allegation: Staff not treating resident with respect and dignity.
Reporting party (RP) stated staff (S1) yelled at R1 when R1 asked for assistance. It was further alleged that staff (S2) laughed at R1 when R1 asked for lighter.
...........continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 4

Control Number 15-AS-20241118162509

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: 11/21/2024

NARRATIVE

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Page 2

R1 stated S1 yelled at R1 when R1 asked for help. R1 also stated when she asked S2 for lighter because her lighter is broken, S2 did not provide and instead laughed at her. Both S1 and S2 denied the allegation. W1 stated he was at the facility when the incident happened and it was R1 who yelled at the staff. Five out of 8 residents interviewed stated not observing staff yelled nor dis-respected R1. One out of the 8 residents stated hearing S1 screamed back when R1 screamed at S1 but does not know what transpired and where it happened. The other resident stated he maybe in his room when the incident about the lighter happened. Due to the medical diagnosis of the other resident, LPA was not able to obtain information.

Based on information obtained, there's not enough preponderance of evidence to prove that a violation occurred, therefore the allegation is closed as unsubstantiated.

Allegation: Staff does not respond to resident's request in a timely manner.
R1 stated when R1 called S1 to help care for her room mate, S1 will not come. R1 also stated when she had something red on her ear and thought it was blood, S1 provided R1 a napkin to blot her ear. S1 did not call 9-1-1 and R1 called 9-1-1 herself. R1 stated it was not blood but a piece of red plastic of unknown origin.

S1 stated she attended to R1 when R1 called her about the blood in R1's ear. S1 stated she checked R1's ear and observed a red dot on the middle outside part of R1's left ear and it's not blood so she gave R1 a napkin but R1 scolded her and called 9-1-1 herself. ADM stated the incident was reported to her by S1.

All staff interviewed stated R1 does not provide care to R1. One of the resident (R6) stated he does not think R1 takes care of R1 and that what R1 thinks of care is down playing others. Due to medical diagnosis, LPA was not able to obtain information from R1's room mate.

Based on information obtained, there's not enough preponderance of evidence to prove that a violation occurred, therefore the allegation is closed as unsubstantiated.

....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20241118162509

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: 11/21/2024

NARRATIVE

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Page 3

Allegation: Staff does not provide resident a safe environment.
R1 stated R2 makes R1 feel threatened, R3 does not allow R1 eat with the rest of the residents and staff are not doing anything about it. R1 also stated that she is not allowed to eat in her room. All staff interviewed stated not observing R2 and R3 threaten and prevent R1 from eating with the rest of the residents. All the staff also stated residents are allowed to eat in their room. LPA observed R1 eating in the dining room with other residents. LPA also observed during investigation 2 residents eating in their rooms. LPA was not able to get information from R2 and R3 regarding the allegation. Therefore, the allegation is unsubstantiated.

Allegation: Staff does not provide adequate food service to resident.
R1 stated S1 would not provide alternative food options and serves certain foods S1 cannot eat. R1 also stated that on 11/19/24, she asked S3 for sandwich because she can not eat meat and S3 did not give her sandwich. S1 stated residents are given substitute if they do not want the food served. S3 stated when R1 asked for sandwich on 11/19/24, she gave R1 peanut butter sandwich and R1 ate the sandwich, pork stroganoff and half of the pasta that was served to R1 that day. Six out of 8 residents interviewed stated there's no issue on the food serve. R4 stated if she does not like the food serve, she is offered substitute. One of the 8 residents stated being serve small servings of salad but didn't ask for seconds. Due to medical diagnosis of one of the resident, LPA was not able to obtain information.

LPAs inspected the food supplies which were observed sufficient and different varieties. LPA Delmundo observed staff served dinner which consisted of pasta with ground pork, salad and fita bread which LPA observed R1 ate.

Based on information obtained, the preponderance of evidence is not met, therefore, the allegation is unsubstantiated.

Allegation: Facility failed to maintain a comfortable room temperature.
R1 stated it's cold in her room. LPAs conducted inspection and observed a portable heater in R1's room. LPA Delmundo tested the temperature at R1's room which was measured at 69.8 degrees Fahrenheit.

....continued on 9099C (page 4)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20241118162509

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: 11/21/2024

NARRATIVE

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All staff interviewed stated the facility has centralized heater which LPA Gharachorloo checked with ADM and observed the temperature at 72 degrees Fahrenheit. However, one of the residents stated it's cold. The other 5 residents stated temperature is comfortable. Due to medical diagnosis, LPA was not able to obtain information from 1 of the resident. Therefore, the allegation is unsubstantiated.

Based on interviews, inspection and observation, all 5 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: 11/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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