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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600585
Report Date: 10/30/2024
Date Signed: 10/30/2024 06:15:20 PM

Document Has Been Signed on 10/30/2024 06:15 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/
DIRECTOR:		ADORA ROSE M SANTIAGOFACILITY TYPE:
735
ADDRESS:22240 MONTGOMERY STREETTELEPHONE:
(510) 886-1813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 20CENSUS: 12DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Aura Rubilyn Bucu/StaffTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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At 3:25 pm on this day, October 30, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with Aura Rubilyn Bucu, staff. LPA called and spoke over the phone with Adora Santiago, administrator (ADM), and informed the reason for visit. ADM stated she was at the facility earlier and just left several minutes ago. ADM authorized Bucu to be with LPA during inspection and to sign and receive this report.

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

LPA toured the facility inside out with Bucu. LPA inspected the kitchen, living room, dining and lounge area, bathrooms, front, side and backyard. LPA randomly selected 7 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 108.6 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced October 16, 2024.

LPA reviewed 5 staff files and interviewed 1 resident. Facility does not handle residents' cash resources.

LPA observed the following:
-at 3:35 pm, rotten wood, collapsed boxes and shopping bags on the side and empty egg case on top of the refrigerator; refrigerator's side dusty; greasy refrigerator doors; kitchen cabinets with splatters; greasy, dirty kitchen floor.

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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: 10/30/2024
NARRATIVE
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-at 3:41 pm, broken and dirty drawers in one of the residents' rooms.
-at 3:45 pm, cabinets with broken drawer and peeled varnish and large plastic bags of personal belongings of former residents in another resident's room. The large plastic bags obstructing the closet where clothes of the current resident are kept.
-at 4:00 pm, shower wall with rust and holes.
-at 5:00 pm, facility does not conduct drill every quarter.

ADM to submit updated copies of the following by November 13, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation within 12 months of deficiency section 80087(a). Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with ADM over the phone in the presence of Bucu.

Due to time constraint, LPA will come back to continue inspection.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/30/2024 06:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/30/2024 at 05:44 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: 10/30/2024

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 cited above in the following which poses a potential health, safety and/or personal rights risk to persons in care: rotten wood, collapsed boxes and shopping bags on the side and empty egg case on top of the refrigerator; refrigerator side dusty; greasy refrigerator doors; kitchen cabinets with splatters; greasy, dirty kitchen floor; broken and dirty drawers in one of the residents' rooms; cabinets with broken drawer and peeled varnish and large plastic bags of personal belongings of former residents in another resident's room. This is a repeat violation. A $250.00 civil penalty is assessed.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator to do the following and submit pictures by 11/13/24:
1. Have the kitchen floor, cabinets and refrigerator cleaned.
2. Fix or replace the borken resident's drawers.
3. Remove the personal properties of former resident from the resident's room.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 in rusted shower wall and with holes which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator to either have shower wall replaced or have it cleaned and fixed. Pictures to be submitted by 11/13/24.
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: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/30/2024 06:15 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/30/2024 at 05:44 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not conducting drills every quarter which poses a potential safety risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator to ensure drills are conducted every quarter and submit self-certification by 11/13/24.
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: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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