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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600585
Report Date: 11/02/2023
Date Signed: 11/02/2023 06:48:22 PM

Document Has Been Signed on 11/02/2023 06:48 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: 12DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Adora Santiago/AdministratorTIME COMPLETED:
06:55 PM
NARRATIVE
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At 10:55 am on this day, November 2, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with Adora Santiago, administrator, and informed the reason for visit.

Facility has Infection Control Plan on file and completed copy submitted to LPA on December 2, 2022.

LPA toured the facility inside out with the administrator. LPA inspected the kitchen, living room, dining and lounge areas, bathrooms, front, side and backyard. LPA randomly selected 5 residents rooms for inspection. Food were checked and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the common bathrooms was tested and measured are 115.5 degrees Fahrenheit. Facility conducts disaster drills, and records showed last conducted October 23, 2023. Fire extinguishers checked, observed fully charge with tags showed serviced October 27, 2022. Administrator stated she'll call to have the extinguishers serviced.

LPA reviewed 5 staff and 5 residents files, and interviewed 3 residents and 2 staff. Medications checked, and compared with records and doctor's orders. Facility does not handle residents' cash resources.

LPA observed the following:
-at 11:15 am, dust in the window sills and window screens in one of the resident's rooms and common area.
-at 11:28 to 11:30 am, tarp, roof waterproofing materials, broken television set and broken exercise machines in the side yard, and broken shopping cart and fluorescent bulb cases in the backyard.

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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: 11/02/2023
NARRATIVE
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-at 12:28 pm, staff (S4) does not have LIC501 Personnel Record and TB test record on file.
-at 12:33 pm, staff (S5) does not have LIC501 Personnel Record on file.
-at 12:38 pm, staff (S3 and S4) who administer medications do have medication training on file.
-at 12:50 pm to 1:20 pm, all 5 residents' LIC625 Appraisal/Needs and Services Plan were over a year old.

LPA received copies of the following current/updated documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report

Administrator to submit an updated LIC610D Emergency Disaster Plan (9 pages) by November 16, 2023.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with administrator. Administrator has to leave and authorized Aura Rubilyn Bucu, staff, to sign and receive this report.

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: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/02/2023 06:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/02/2023 at 05:56 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: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 above for dust in window sills and window screens, and items in the yard such as tarp, roof waterproofing materials, broken television set, exercise machines and shopping cart, and flourescent bulb cases which pose a potential health and safety risks to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Administrator to have the window sills and screens and yards cleaned. Pictures to be submitted by 11/16/23.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for S4 not having TB test record on file which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Administrator to have the staff TB tested and submit copy of result by 11/16/23.
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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/02/2023 06:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/02/2023 at 05:56 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: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above for S3 ands S4 not having medication training on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Administrator to have the staff trained and submit proof by 11/16/23.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.


This requirement is not met as evidenced by
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section above for S4 and S5 not having LIC501 on file which pose a potential personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Administrator to complete the LIC501s and submit copies by 11/16/23.
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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2023 06:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/02/2023 at 06:22 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: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
85068.3 Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents' LIC625 over a year old which poses/posed a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Administrator to update the LIC625s and submit self-certification it's completed by 11/16/23.
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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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