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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600585
Report Date: 11/05/2024
Date Signed: 11/05/2024 06:37:30 PM

Document Has Been Signed on 11/05/2024 06:37 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:
11/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Aura Rubilyn 'Ruby' Bucu/StaffTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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At 3:15 pm on this day, November 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual inspection that was started on October 30, 2024 and met with Aura Rubilyn 'Ruby' Bucu, staff. LPA called and spoke over the phone with Adora Santiago, administrator (ADM), and informed the reason for visit.

LPA reviewed 5 residents' records. Medications were inspected and compared with doctor's orders and LIC622 Centrally Stored Medication Records.

LPA observed the following:
-at 3:40 pm, R1's LIC602 showed R1 ambulatory, not consistent with R1's non-ambulatory status. R1 uses cane and walker for mobility.
-at 3:55 pm, resident's (R2) LIC602A Physician's Report was signed by social worker (LCSW).
-at 4:10 pm, resident (R5) has no LIC9172 Functional Capability Assessment on file.
-at 4:35 pm, R1 lists/order of medications on file do not have the frequency of administration. Medications filled on 10/2024 do not have LIC622 Centrally Stored Medication and Destruction Record.
-at 4:50 pm, resident(R2) has doctor's order/recent medication list on file dated 8/2024 but facility does not have the following medications: clotrimazole; lidocane cream; Aquaphor; trihexyphenidyl. Carbamazepine and Haloperidol are 100 mg and 5 mg but the medications in the facility are 200 mg and 10 mg respectively. Medications filled on 10/2024 have no LIC622.
-at 5:05 pm, there's no doctor's order for R3's 10 medications. Medications filled on 10/2024 have no LIC622.

...continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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: 11/05/2024
NARRATIVE
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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 ADM over the phone in the presence of Ruby Bucu.

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: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/05/2024 06:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2024 at 05:43 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in the following which pose an immediate health and/or personal rights risks to persons in care: R1 lists/order of medications on file do have the frequency of administration; facility does not have the 4 medications listed on R2's most current order & 2 of the medications do not match the dosage listed; there's no doctor's order for R3's 10 medications
POC Due Date: 11/06/2024
Plan of Correction
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Administrator to do the following and submit proof by 11/06/24:
(1) Obtain complete doctor's order for R1's medications; (2) Check with R2's doctor if medications are no longer needed and obtain discontinued order; otherwise obtain the medications; (3) Obtain doctor's order for R3's medications.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/05/2024 06:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2024 at 05:43 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

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 R5 not having LIC9172 on file which poses potential health, safety and/orpersonal rights risks to person in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator to complete the LIC9172 and submit copy by 11/19/24.
Type B
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in R1's LIC602 not consistent with R1's current non-ambulatory status which poses a potential health, safety and/or personal rights risks to person in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator to have R1's LIC602 updated and submit copy by 11/19/24.
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: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/05/2024 06:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2024 at 06:02 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
80069 Client Medical Assessment
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in R2’s LIC602A signed by a social worker which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator to have the LIC602A completed and signed by a physician.
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


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 cited above in R1, R2 and R3's medications filled on October 2024 not having LIC622s which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator to complete the LIC622s and submit self-certification by 11/19/24.
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: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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