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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600585
Report Date: 01/13/2023
Date Signed: 01/13/2023 06:22:20 PM

Substantiated


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
01/10/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230110094614
FACILITY NAME:VILLA MONTGOMERYFACILITY NUMBER:
015600585
ADMINISTRATOR:ADORA ROSE M SANTIAGOFACILITY TYPE:
735
ADDRESS:22240 MONTGOMERY STREETTELEPHONE:
(510) 886-1813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:20CENSUS: 16DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Aura Rubilyn 'Ruby' Bucu/StaffTIME COMPLETED:
06:25 PM
ALLEGATION(S):
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Facility roof is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Aura Rubilyn 'Ruby' Bucu. LPA called and spoke with Adora Santiago, administrator. LPA informed the purpose of visit. Administrator authorized Aura Rubilyn Bucu to sign and receive this report.

During the investigation, LPA observed pails and pan in the hallway and a container in the dining to catch the water dripping from the ceiling and a bucket in resident's (R1) room. The administrator stated the roof started leaking about a week and a half ago, and the contractor started the repair. . Staff (S1) stated the roof is leaking and R1 stated there was a leak R1's room.

Based on observation and interviews, the preponderance standard is met, therefore the allegation is substanitated.

......continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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 3
Control Number 15-AS-20230110094614
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: VILLA MONTGOMERY
FACILITY NUMBER: 015600585
VISIT DATE: 01/13/2023
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with administrator over the phone.

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: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230110094614
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: VILLA MONTGOMERY
FACILITY NUMBER: 015600585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
80087(a)
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80087Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

-This requirement is not met as evidenced by:
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Administrator to come up with a plan to keep the residents safe while repair of roof is in progress, and submit the plan by 01/14.2023. Proof of repair is completed to be submitted by 01/27/2023
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-Based on observation and interviews, the licensee did not comply with the section above. The roof is leaking which poses potential health and safety risks to persons 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3