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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 02/14/2025
Date Signed: 02/14/2025 05:42:13 PM

Document Has Been Signed on 02/14/2025 05:42 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: 13DATE:
02/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:50 PM
MET WITH:Mirriam Paras/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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While at the facility investigating a complaint (Control # 15-AS-20250206094236) and upon review of resident's (R1) file, Licensing Program Analyst (LPA) Delmundo observed R1 has prescribed antibiotics medication to be administered 3 times a day for 3 days. The medication was received by the facility on 2/06/25 and administration was started same day; however, the medication was not recorded on LIC622 Centrally Stored Medication and Destruction Record nor administration of this medication recorded on Medication Administration Record (MAR). Staff (S1) stated the medication was received and administered but she didn't record. These were discussed with Mirriam Paras, administrator (ADM).

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

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

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/14/2025 05:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/14/2025 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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Administrator to do the following and submit proof by 2/28/25:
1. Complete the LIC622.
2. In-service the staff.
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-This requirement is not met as evidenced by:
-Based on record review and interview, the licensee did not comply with the section above in not completing the record when R1's medication was received and administered which posed a potential personal rights risk to person in care.
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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: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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