015601506-8-14-2025-15-AS-BFOG-DKXKAL-20250827074406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 08/14/2025
Date Signed: 08/14/2025 08:42:35 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
08/08/2025 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20250808113155

FACILITY NAME:	MONTGOMERY SPRINGS MANOR		FACILITY NUMBER:	015601506
ADMINISTRATOR:	MIRRIAM PARAS		FACILITY TYPE:	740
ADDRESS:	22107 MONTGOMERY STREET		TELEPHONE:	(510) 889-8556
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	15	CENSUS: 14	DATE:	08/14/2025
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Mirriam Paras/Administrator		TIME COMPLETED:	08:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff do not provide modified diet to resident.

-Staff do not provide appropriate care to the resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day, August 14, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations and met with staff, Jonalyn Legarto. LPA called and spoke with Mirriam Paras, administrator (ADM), and informed the reason for visit. ADM arrived at around 12:17 pm.

LPA reviewed residents's files and obtained copies of the following documents: LIC601 Identification and Emergency Information; Face Sheet; LIC602A Physician's Reports; doctor's order; facility notes. LPA inteviewed staff (S1, S2, S3 and ADM) and residents (R1, R2, R3, R4), and conducted inspection.

Allegation: Staff do not provide modified diet to resident.
Reporting party (RP) reported that resident (R1) indicated calling R1's social worker and the facility staff has been advised to give R1 soft foods; however, according to R1, R1 is not being fed with food R1 can eat.

....continued on 9099C(page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 3

Control Number 15-AS-20250808113155

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: 08/14/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2

Review of R1's record showed request to update R1's diet order to reflect R1's preference which the doctor approved. Approved order showed low-fat diet, cut-up texture, thin liquid with special instruction of no milk, apples, nuts and to provide R1 softer food and food preferred by R1 such as tender meat with sauces, soft fruits such as bananas, fruit cups, apple sauce and soft vegetables.

LPA observed the meal served for lunch on this day consisted of pasta with ground meat, steamed vegetables and fresh fruit for dessert. LPA observed the dinner prepared by S1 consisted of mash potato, tender chicken with sauce and steamed vegetables. Food supplies were inspected and observed of different varieties which includes apple sauce, fruit cups, canned mixed fruits, fresh bananas and other fresh fruits.

Review of other resident's LIC602A showed R2 and R3 with special diet. R2 stated the staff does not give R2 food that is indicated in LIC602A not to be given to R2. R2 stated she can not have food with tomato and tomato sauce and that she is given other meal option when food to be served has tomato and/or tomato sauce. R3 stated she is happy with the food serve. R4 who is not on special diet stated he is given option when the meal is that of R4's preference. R1 stated staff cut the food serve to her to small pieces.

All staff interviewed stated R1 is served soft food. S2 and S3 stated R1 is served food cut into pieces. S1 also stated she cuts the food served to R1 except burrito because R1 does like it to be cut. R1 has fruit cups.

Based on information obtained, the allegation is unsubstantiated.

Allegation: Staff do not provide appropriate care to the resident.
RP stated that R1 feels that R1's care needs are neglected by staff.

The 2 staff who are providing assistance to R1 denied the allegation and stated that whenever R1 calls for help, they assist. They assist other residents who need assistance.

......continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20250808113155

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: 08/14/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 3

R1 stated staff assist her with activities of daily living (ADLs) and when she calls for help. Two of the other 3 residents stated the staff assist them whenever they need help while one of these 3 residents stated not needing assistance with ADLs. One of these 3 residents stated not observing staff not providing assistance whenever R1 calls for help. Therefore, the allegation is unsubstantiated.

Based on interviews, inspection, observation and records review, the 2 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: 08/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3