015601506-2-23-2024-15-AS-HHUL-D2VUA2-20240228142400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:12:41 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
02/21/2024 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240221085509

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: 13	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mirriam Paras, Administrator		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff called the residents inappropriate names while in care

Staff do not provide adequate care and supervision to the residents

INVESTIGATION FINDINGS:

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On 2/23/2024 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit for the above allegation. LPA met with Mirriam Paras, Administrator, and explained the reason for the visit.

During the visit LPA interviewed four (4) staff, residents, obtained the facility resident list and personnel record (LIC500) dated 2/26/2023. Other residents were not able to be interviewed due to diagnosis or absence from facility.

Allegation: Staff called the residents inappropriate names while in care.

During interviews three (3) residents stated that they have not heard any staff call residents names. Only one (1) resident stated that staff member calls residents names. Staff stated during interview that no other staff calls residents names or speaks to residents in appropriately. LPA did not observe any residents being nervous of afraid around staff

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240221085509

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: 02/23/2024

NARRATIVE

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Continued from LIC9099.

Allegation: Staff do not provide adequate care and supervision to the residents

Residents stated during interview if they require any medical assistance or just help in the facility the staff will oblige. Staff stated during interview that if the residents require help that they can not provide they would notify the Administrator or call 9-1-1. LPA observed Residents in care appear to be safe, groomed, and there are no imminent health/safety concerns on today's date.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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