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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 06:44:41 PM

Document Has Been Signed on 11/02/2023 06:44 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Adora SantiagoTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management in response to the SOC341 Report of Suspected Dependent Adul/Elder Abuse received by Oakland Regional Office from different agency. SOC341 indicated that resident (R1) received SSI and R1's father is the rep payee. R1 should get $116/month spending money but only receives $20.

On this day, November 2, 2023, LPA met with Adora Santiago, administrator, and informed the reason for visit.

LPA reviewed R1's file and obtained copies of documents. LPA conducted interviews. Facility does not handle resident's P&I.

No deficiency cited.

Administrator has to leave and authorized Aura Rubilyn Bucu, staff, to sign and receive this report.

Exit interview conducted .
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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