Community Care Licensing

Document Has Been Signed on 03/05/2025 09:15 PM - It Cannot Be Edited

FACILITY NAME:	MONTGOMERY SPRINGS MANOR		FACILITY NUMBER:	015601506
ADMINISTRATOR/ DIRECTOR:	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:	03/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Mirriam Paras/Administrator		TIME VISIT/ INSPECTION COMPLETED:	09:15 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
	VISIT DATE: 03/05/2025

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
	VISIT DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type A

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risk to persons in care: unlocked pocket utility knife, skin protector, razor, cleaning supplies, construction tool, pails and gallons of paint and staff medications. This is a repeat violation. A $250.00 civil penalty is assessed.
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	Staff locked the items and the gate to the side yard. In addition, administrator to in-service the staff and submit proof by 3/07/25.

Type A

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health and/or personal rights risks to persons in care: rotten mushrooms, Serrano peppers, radish, celery and carrots with mold in the refrigerator
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	Administrator discarded the items. In addition, administrator to do the following and submit proof by 3/07/25: 1. Have all the food supplies checked. 2. In-service the staff.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type A

Section Cited

CCR

87555(b)(9)

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which poses an immediate health and/or personal rights risks to persons in care: food items in the refrigerator still in the shopping bags and box packaging materials; sausage links and Bologna in open plastic packaging material.
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	Staff removed the shopping bags and put the sausage links in a Ziplock and threw away the Bologna. In addition, administrator to in-service the staff and submit proof by 3/06/25.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type B

Section Cited

CCR

87303(a)

(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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: rusted dirty dining chairs and trash cans; cracked cement in between transition and heavily scratched door post in the common bathroom; broken night stand door & heavily soiled upholstered chair in resident's room; stained stairs carpet covering; shower door with mildew and water damaged lavatory with stained faucet; debris/garbage in the backyard and ramp; dusty exit door. A $250.00 civil penalty assessed for repeat violation.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to have following done and submit proof by 3/19/25: (1) Purchase trash cans and dining chairs; (2) Repair/fixed the cement cracks; (3) Repaint; (4) Repair or replace the night stand; (5) Purchase and replace the chair in the resident's room; (6) Deep cleaned the stairs's steps; (7) Clean the shower; (8) Replace/repair the lavatory; (9) Clean the yard, ramp and door.

Type B

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having CPR certified staff which poses a potential health, safety and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll have the staff complete CPR training. Proof to be submitted by 3/19/25.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in S3 and S5 not having restricted health conditions training for 2024 which pose a potential health and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll have the staff complete the training. Proof to be submitted by 3/19/25.

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in S3 and S5 not having the required/ complete number hours of medication training which pose a potential health and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll have the staff complete the training. Proof to be submitted by 3/19/25.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type B

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in R1 not having a pre-placement appraisal which posed a potential health, safety and/orr personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to complete the appraisal and submit copy by 3/19/25.

Type B

Section Cited

CCR

87457(c)(1)(A)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review], the licensee did not comply with the section cited above in R1 not having a LIC9172 Functional Capability Assessment which poses a potential health, safety and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to complete the LIC9172 and submit copy by 3/19/25.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type B

Section Cited

CCR

87463(i)

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in R3, R4 and R5's LIC625 missing 2 pages and R3 and R4's not signed by the residents and/or residents's responsible person which posed a potential health, and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to complete the LIC625s, review with the resident and/or residents' responsible person and have the documents signed. Self-certification to be submitted by 3/19/25.

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S5 not First Aid certified which poses a potential health, safety and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll have the staff trained. Copy of certificate to be submitted by 3/19/25.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having doctor's orders for R1 and R3's bed rails which pose a potential safety and/or personal rights risks to persons in care. This is a repeat violation. A $250.00 civil penalty is assessed.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll obtain doctor's orders. Copies to be submitted by 3/19/25.

Type B

Section Cited

CCR

87506(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in R5's two medications incorrectly recorded on LIC622 which pose potential health and/or personal rights risks to persons in care. This is a repeat violation. A $250.00 civil penalty is assessed.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to have the record corrected and in-service the staff. Proof to be submitted by 3/19/25.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025

Link to Parent Document Below:

FACILITY NAME: MONTGOMERY SPRINGS MANOR	FACILITY NUMBER: 015601506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

Type B

Section Cited

CCR

87411(d)(1)

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S4, a cook, not having the required training which poses a potential health and/or personal rights risk to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to have the staff trained and submit proof by 3/19/25.

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents…….This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S4 not having LIC503 and S3's LIC503 incomplete which pose a potential health and/or personal rights risks to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Administrator to have the staff health screened and submit copies of LIC503 by 3/19/25.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025