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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600585
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:04:08 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
03/09/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20230309134921
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: 14DATE:
03/16/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Aura Rubilyn BucuTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff speaks to resident in an inappropriate manner.
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INVESTIGATION FINDINGS:
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On 03/16/2023 at 10:40am, Licensing Program Analyst (LPA), Carol Fowler conducted an unannounced 10- day complaint investigation to present the above allegations. LPA was met by Caregiver, Aura Rubilyn Bucu LPA C. Fowler spoke with Administrator, Adora Rose Santiago to inform her of the above allegations.

During the investigation, LPA conducted interviews with 4 clients and 4 staff and obtained and reviewed the following documents: client information sheet, identification and emergency information, preplacement and physicians report.

Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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-20230309134921
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: 03/16/2023
NARRATIVE
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Continue from LIC9099

LPA Interviews with clients and staff which revealed that staff spoke inappropriately to clients in care at the facility. C1 stated that C1 heard staff speak inappropriately to other clients. C3 stated there was a man working on the roof and he walked into the facility and he was speaking inappropriate to clients. Staff stated that sometimes there are other staff speaking loudly to clients if they are not following directions. Staff also stated that a staff member speaks inappropriately to clients when working at the facility. Staff also stated that they do not have time to talk to clients and staff also stated that staff tells clients to go and talk with other staff.

Based on LPA observations, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230309134921
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: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s residential facilities, each client shall have personal rights ...limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidence by:
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Administrator will conduct in-service with all staff on dignity and relationships with clients and provide CCLD with signatures of staff attendance no later then the POC date.
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Based on LPA observation licensee did not comply with the section cited above by staff speaking to clients in an inappropriate manner which poses a otential health and safety risk to clients 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: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3