015601506-2-14-2025-15-AS-BFOG-DE92FK-20250225162140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 02/14/2025
Date Signed: 02/14/2025 05:37:08 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
02/06/2025 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20250206094236

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:	02/14/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mirriam Paras/Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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-Staff are not ensuring that resident receives their medication(s) as prescribed.

-Facility is in disrepair.

-Staff not treating resident with respect and dignity.

INVESTIGATION FINDINGS:

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On this day, 2/14/25, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with staff, Jonalyn Legarto, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM), who arrived at around 12:10 pm.

LPA reviewed resident's (R1) file and obtained copies of the following: ePrescription; LIC622 Centrally Stored Medication and Destruction Records; Medication Administration Record. LPA conducted inspection with the Jonalyn Legarto and interviewed staff (S1, S2, S3 and ADM), resident (R2) and R1's doctor (PCP1).

Allegation: Staff are not ensuring that resident receives their medication(s) as prescribed.
On 2/06/25, R1 stated that R1 tested positive of UTI on 1/31/25 and PCP1 prescribed medications but R1 has still not received the medication and staff are not making sure that prescription is picked up.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250206094236

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: 02/14/2025

NARRATIVE

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Review of records showed facility has copy of ePrescription dated 2/01/25 with antibiotics prescribed 3 times a day for 3 days with out-of-state pharmacy listed and with comments 'deliver by CPN tomorrow'. This document showed received 2/06/25. PCP1 stated that PCP1 prescribed the antibiotics on 1/31/25 and that if the medications need to be delivered immediately, it should be delivered by the local pharmacy. PCP1 stated that it could be pharmacy issue that the medication was not delivered the following day the prescription was written. S1 stated she only came to know about the prescription and was only informed by R1 once. S1 and ADM stated they called the Center for Elder's Independence to follow-up. S1 stated the medication was received on 2/06/25 and started the administration dinner time on 2/06/25. Based on information gathered, the allegation is unsubstantiated.

Allegation: Facility is in disrepair.
R1 stated that residents have to put their used (soiled) toilet paper in the garbage because they are not allowed to flush the toilet paper in the toilets. R1 also stated that staff tell residents to use the garbage because if they flush the toilet paper the toilets get clogged up.

LPA conducted inspection and flushed all the toilets. LPA observed all the toilets draining properly. The 3 staff, ADM and R2 stated the toilet in the big bathroom was not draining properly but did not overflow, and was replaced with a new one recently. Therefore, the allegation is unsubstantiated.

Allegation: Staff not treating resident with respect and dignity.
R1 stated that when R1 was asking S1 about R1's antibiotics medication, S1 told R1 to shut up. S2 and S3 stated not hearing S1 and denied telling R1 such. R2 stated not hearing S1 or other staff respond to any residents inappropriately. Therefore, the allegation is unsubstantiated.

Based on review of records, interviews and inspection, the 3 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: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC9099 (FAS) - (06/04)

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