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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600585
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:16:17 PM

Document Has Been Signed on 11/09/2021 02:16 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: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: 15DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Aura Rubilyn 'Ruby' Bucu/StaffTIME COMPLETED:
11:57 AM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Aura Rubilyn 'Ruby' Bucu. LPA called and spoke with Adora Santiago, administrator. LPA informed both of them the purpose of visit. Adora authorized Ruby to be with LPA during inspection. Adora arrived after about an hour and half. LPA also met with other staff, Franc Metiam.

Facility has completed COVID-19 mitigation plan and submitted to Community Care Licensing (CCL). LPA observed screening station located by the entrance door with visitor's log, hand sanitizer and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done for all staff, residents and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. Staff were observed wearing mask. Supplies of centrally stored PPEs inspected.

LPA inspected the facility inside out with Ruby. LPA randomly selected 6 residents and 2 staff rooms for inspection. LPA also inspected 3 common bathrooms, staff bathroom, dining area, kitchen, laundry room, front and side yards and backyard.

There were at least 7 days of nonperishable and 2 days of perishable foods. Fire extinguishers were observed fully charge and tags showed serviced April 7, 2021. Hot water temperature in the 1 of the bathroom sinks was tested and measured at 105.6 degrees Fahrenheit.

LPA observed the following:
1. Worn out mattress in the backyard.
2. No sneeze and cough etiquette poster in the dining area and hand washing posters in 3 resident bathrooms. No 6 feet physical distancing signs.

....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/09/2021
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3. Visitors poster on facility entrance outdated and no "Wear mask" poster.
4. Trash cans without lids in all 4 bathrooms and dining area, and trash can's lid in the kitchen not "touch free".
5. Supplies of N95 respirators, surgical masks and disposable gloves not sufficient for 30 days.
6. Staff were not fit tested for N95 respirators.
7. Beds in some of the shared bedrooms are less that 6 ft apart.

Administrator to submit the following updated documents to CCL by November 23, 2021:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan

Deficiency is cited from Title 22 California Code of Regulations (see 809D). 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 Adora Santiago.

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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2021 02:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/09/2021 at 01:27 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: VILLA MONTGOMERY
FACILITY NUMBER: 015600585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed worn out matress in the backyard which poses potential personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Administrator to dispose the mattress and submit picture by 11/23/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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