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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 05/01/2025
Date Signed: 05/01/2025 07:42:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250430080657
FACILITY NAME:MONTGOMERY SPRINGS MANORFACILITY NUMBER:
015601506
ADMINISTRATOR:MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:22107 MONTGOMERY STREETTELEPHONE:
(510) 889-8556
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 14DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:MIrriam Paras/AdministratorTIME COMPLETED:
07:45 PM
ALLEGATION(S):
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-Staff does not ensure food is of good quality for residents in care.
-Staff allow residents to be left in soiled clothing for extended periods of time.
-Staff does not ensure residents receive adequate hydration.
-Staff do not ensure resident has personal privacy.
-Staff do not ensure residents are provided supervision.
INVESTIGATION FINDINGS:
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On this day, May 1, 2025, at 11:05 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with staff, Melody Tria, and informed the reason for visit. MIrriam Paras, administrator (ADM) arrived around 11:40 am.

LPA inspected the food supplies and obtained copy of LIC9020 Register of Facility Clients/Residents. LPA reviewed residents' files and obtain copies R1's following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Plan. LPA interviewed residents (R1, R2, R3, R4, R5, R6) and staff (S1, S2, S3 and ADM).


....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20250430080657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506
VISIT DATE: 05/01/2025
NARRATIVE
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Page 2

Allegation: Staff does not ensure food is of good quality for residents in care.
All 4 staff interviewed stated residents are never serve hard bread and/or stale food. LPA inspected the food supplies and didn't observed stale and/or expired food. Resident (R1) stated the staff serve bread that is hard and stale. Three out of the 5 other residents stated food serve is good and that staff never serve stale food. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated.

Allegation: Staff allow residents to be left in soiled clothing for extended periods of time.
R1 stated staff do not change residents out of their urine filled diapers and will leave them in soiled diapers all day. LPA conducted inspection and did not observed any resident smelling urine or soaking wet. The 3 staff stated they change residents who need assistance in changing diapers at least 3x during their shift. ADM stated residents are changed 9x in 24 hours and as needed. Two out of the 5 other residents can toilet on their own. One of these 5 residents stated wearing diaper but does not need assistance in changing. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated.

Allegation: Staff does not ensure residents receive adequate hydration.
R1 stated that the staff do not provide water or other fluids to residents to drink throughout the day except during meal time. All four staff interviewed stated residents are provided water, juice, coffee and/or tea during meals. Water is also provided during snacks time and when medications are administered. Three out of 5 residents stated they are provided water and juice during meals. They also stated they have water containers in their rooms which the staff filled regularly. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated.

Allegation: Staff do not ensure resident has personal privacy.
R1 stated that R1's room mate has dementia and wakes up R1 constantly when R1 tries to sleep.

.....continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250430080657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506
VISIT DATE: 05/01/2025
NARRATIVE
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Page 3

Two of the 4 staff stated when R1 has a visitor, the visitor comes inside R1's room shared with R5. R1 would not want R5 to be inside the room so they keep R5 in the living room. One of these staff stated R1 stays outside the room, however, when R5 is already sleepy, she asks R1 and tell that R5 wants to sleep. Three out the other 5 residents stated staff accord them privacy. Due to medical diagnosis, LPA was not able to obtain information from R5. Therefore, the allegation is unsubstantiated.

Allegation: Staff do not ensure residents are provided supervision.
R1 stated that another resident grabbed R1's arm hard a month ago and that R1 called the staff but the staff did not come to help. All four staff and 3 out the other 5 residents stated not observing the incident. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated.

Based on interviews, inspection, observation and records review, the 5 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250430080657

FACILITY NAME:MONTGOMERY SPRINGS MANORFACILITY NUMBER:
015601506
ADMINISTRATOR:MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:22107 MONTGOMERY STREETTELEPHONE:
(510) 889-8556
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 14DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:MIrriam Paras/AdministratorTIME COMPLETED:
07:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff do not provide meal substitutions for residents in care.
-Staff does not ensure facility has adequate food supply for residents in care.
-Licensee does not ensure staff receive training in CPR.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
On this day, May 1, 2025, at 11:05 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Melody Tria, and informed the reason for visit. MIrriam Paras, administrator (ADM) arrived around 11:40 am.

LPA inspected the food supplies and obtained copy of LIC9020 Register of Facility Clients/Residents. LPA reviewed resident's file and obtain copies of the following R1's documents: LIC601 Identification and Emergency Contact Information; LIC602A; Progress Notes from medical provider; LIC625 Appraisal/Needs and Services Plan. LPA interviewed residents (R1, R2, R3, R4, R5, R6) and staff (S1, S2, S3 and ADM).

....continued on 9099C (page 2)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250430080657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506
VISIT DATE: 05/01/2025
NARRATIVE
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Page 2

Allegation: Staff do not provide meal substitutions for residents in care.


R1 stated that R1 has a hard time eating and cannot eat the meat but the staff do not offer substitute. LPA reviewed R1's file which didn't indicate R1 cannot eat meat. Progress Notes from medical provider dated 9/30/24 showed approved diet order which includes food minced and soft. LPA observed during lunch other residents were served fried chicken, mixed vegetables, potato salad and fresh fruit while R1's was served fish fillet cut into small pieces served with tartar sauce, mixed vegetables, potato salad and fresh fruits. R1 told LPA that the fish fillet were hard; however, when LPA tested in front of R1, the fish fillets were soft. The 4 staff interviewed stated they provide substitute. One of these 4 stated stated that R1 began complaining of not wanting to eat meat about 4, 5 days ago, but R1 ate hamburger 2 days ago. R1 wants R1's food cut into pieces in front of R1, which the staff do. Therefore, the allegation is unfounded.

Allegation: Staff does not ensure facility has adequate food supply for residents in care.

The 3 staff stated that ADM does food shopping 2x a month which LPA confirmed with ADM. All these 4 staff stated they never run out of food supplies. LPA inspected the food supplies and observed more than adequate. Therefore, the allegation is unfounded.

Allegation: Licensee does not ensure staff receive training in CPR.

R1 stated the staff are not CPR certified and don't do anything when a resident is choking on food and will only give the residents water.

All staff interviewed stated there was no incident of resident choking. LPA has not received incident report from the facility indicating resident(s) choked. The staff interviewed stated that R1 thinks that when R5 coughs, R5 is choking. R5 observed R5 wearing mask and R5 stated she's coughing. During investigation, LPA heard R5 coughing. LPA checked the 5 staff records which showed all of them have current First Aid certificate. Therefore, the allegation is unfounded.

Based on interviews, records review, inspection and observation, the 3 allegations are closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiency cited. Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5