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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600585
Report Date: 11/05/2025
Date Signed: 11/05/2025 06:01:04 PM

Document Has Been Signed on 11/05/2025 06:01 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: 11DATE:
11/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH: Adora Santiago/AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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At 12:15 pm on this day, November 5, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with Adora Santiago, administrator (ADM) and informed the reason for visit.

LPA toured the facility inside out with ADM. LPA inspected the kitchen, living room, dining and lounge area, 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 in operating condition on this day. Hot water temperature in one of the common bathrooms was tested and measured are 113.5 degrees Fahrenheit. Fire extinguishers checked, observed fully charge, however tags showed serviced October 16, 2024. ADM stated she'll call for service tomorrow, 11/06/25. Facility conducts disaster drills and records showed last conducted 9/29/25.

LPA reviewed 4 staff and 5 resident files, and interviewed 2 residents. Facility does not handle residents' cash resources.


....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/05/2025
NARRATIVE
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LPA observed the following:
-at 12:28 pm, chipped flooring in one of the residents rooms.
-at 1:00 pm, administrator's certificate expired on 02/2025. ADM stated she submitted the 40 hours required training before 02/2025, however, it was denied due to the last name on the training certificates do not match the last name on Administration Certification Bureau's (ACB) system.
-from 1:30 pm to 2:00 pm, 3 out of 4 staff's first aid certificates expired.
-from 2:10 pm to 2:30 pm, 3 out of 5 residents are over 60 years of age with no approved age exception request on file.
-at 2:45 pm, resident's (R5) does not have TB test result nor have record indicating TB test done.
-two of R1's medication on facility's hand do not match the order. Facility does not have 3 of the medications listed on the order/list.
-facility has 2 medications for resident (R4) and are listed on 11/2025 LIC622 Centrally Stored Medication and Destruction Record but not on most current doctor's order on file.

On this day, LPA received updated copies of the following documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan

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.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/05/2025 06:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2025 at 05:08 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: 11/05/2025

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in the following which pose an immediate health and/or personal rights risk to persons in care: 2 of R1's medication on facility's hand do not match the order; facility does not have 3 of the medications listed on the medication order/list for R1's
POC Due Date: 11/06/2025
Plan of Correction
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Administrator stated she'll check with the medical provider and submit current order. If the 3 medications are no longer needed, to obtain discontinued order. Proof to be submitted by 11/06/25.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 06:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2025 at 05:08 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: 11/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

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 in not having doctor's order for 2 of R4's medications which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Administrator to obtain doctor's order. If the medications are no longer needed, to discontinue administration. Proof to be submitted by 11/06/25.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 06:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2025 at 05:08 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: 11/05/2025

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 chipped laminate flooring in resident's room which poses a potential personal rights risk to person in care.
POC Due Date: 11/19/2025
Plan of Correction
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Administrator stated she'll have the flooring fixed. Picture to be submitted by 11/19/25.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 in S1, S2 and S4's first aid certificates expired which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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Administrator to have staff register for training and submit copies of certificates by 11/19/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 11/05/2025 06:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/05/2025 at 05:08 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: 11/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

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 in not having TB test and result for R5 which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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2
3
4
Administrator to have the resident TB tested and submit copy of result by 11/19/25.
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interview with administrator, the licensee did not comply with the section cited above in 3 of the residents over 60 years of age which exceeds the allowable 25% of the census which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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2
3
4
Administrator stated she'll submit age exception requests. Requests to be submitted by 11/19/25 along with supporting documents including but not limited to LIC602A Physician's Report, updated LIC625 Appraisal/Needs and Services Plan, letter from responsible person(s) supporting the stay of the residents, staff training
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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