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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 03/24/2026
Date Signed: 03/24/2026 07:24:47 PM

Document Has Been Signed on 03/24/2026 07:24 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:MONTGOMERY SPRINGS MANORFACILITY NUMBER:
015601506
ADMINISTRATOR/
DIRECTOR:		MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:22107 MONTGOMERY STREETTELEPHONE:
(510) 889-8556
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 11DATE:
03/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:S2 not having LIC501 on file TIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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On this day, March 24, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Jonalyn Legarto, and informed the reason for visit. LPA called and left message on Mirriam Paras', administrator (ADM), voicemail. ADM arrived at around 12:06 pm. LPA also met with other staff, Charlaine Rose De Leon and Melody Tria.

LPA started the inspection with Jonalyn Legarto and continued with ADM. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked.

Hot water temperature in one of common bathrooms was tested and measured at 117.8 degrees Fahrenheit. Fire extinguishers were observed fully charge with tags showed serviced September 24, 2025. Carbon monoxide and smoke detectors were tested and observed in operating condition during today's visit. Facility only conduct fire drills and records showed conducted January 16, 2025 and February 8, 2026.


LPA reviewed 5 residents and 5 staff files and interviewed 1 resident. Residents medications were checked. Facility does not handle residents' cash resources and/or P&I.


.....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506
VISIT DATE: 03/24/2026
NARRATIVE
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LPA learned that one of the residents (R6) was sent out to the hospital on March 3, 2026 but the facility did not submit incident report.

LPA observed the following:
-at 11:37 am, unlocked cabinet where peritoneal cleanser are kept.
-at 11:40 am, half bed rails of 2 residents have no doctor's order on file.
-at 11:45 am, broken drawer knob in residents' room.
-at 11:58 am, broken glass window in resident's room; cat's feces, rusted paint pan, paint roller, piece of wood and metal in top stairs leading to the backyard.
-at 12:04 pm, Neosporin and muscle rub in resident's room.
-at 12:09 pm, unlocked gate leading to storage where cleaning supplies are kept and Clorox bleach in the backyard.
-at 12:15 pm, pieces of wood, rusted grills, soiled placemat, empty milk container on the backyard ground.
-at 12:17 pm, rubbing alcohol, rust remover and hammer in unlocked basement room.
-at 12:30 pm, rusted sink and medications in unlocked refrigerator in area adjacent to the kitchen
-at 1:00 pm, two residents' beds with half bed rails but no doctor's order on file.
-at 3:00 pm, staff (S2) has no LIC501 Personnel Record on file.
-at 3:15 pm, staff (S3), a cook, does not have food preparation training on file
-at 3:30 pm, records showed facility does not conduct disaster drills every quarter and only conducted fire drills.
-at 4:15 pm, residents' (R1 and R2) LIC602A Physician's Report/medical assessments on file are over a year old.
-all 5 residents have no doctor's orders for current medications.



.......continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506
VISIT DATE: 03/24/2026
NARRATIVE
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Administrator to submit updated/current copies of the following by April 7, 2026:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of $3M Liability Insurance coverage

Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. A $250.00 civil penalties for each of section # 87303(a), 87463(h) for repeat violations within 12 month period and will continue for $100.00/day until corrected. Failure to submit proof of corrections for other deficiencies may also result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the ADM.

Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, 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: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 03/24/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/24/2026 at 06:11 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: Neosporin and muscle rub in resident's room; unlocked gate leading to storage where cleaning and laundry supplies are kept; Clorox bleach in the backyard; rubbing alcohol, rust remover and hammer in unlocked basement room; unlocked peritoneal cleanser and medications
POC Due Date: 03/25/2026
Plan of Correction
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Staff locked the medications and gate. Administrator have the basement cleaned and discarded the items in the basement.
In addition, administrator to in-service the staff and submit copy of training topics with attendees signatures by 3/25/26.
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) 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 resident'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 records review, the licensee did not comply with the section cited above in residents current medications not having doctor's orders on file which pose an immediate health and/orr personal rights risks to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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2
3
4
Administrator stated she'll obtain doctor's orders. Copies to be submitted by 3/25/26.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 03/24/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/24/2026 at 06:11 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above in not submitting incident report when one of the residents was sent out to the hospital which posed a potential personal rights risk to person in care.
POC Due Date: 04/07/2026
Plan of Correction
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Administrator to submit incident report by POC date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: broken glass window; cat's feces, rusted paint pan, paint roller, piece of wood and metal on top stairs; rusted sink in area adjacent to kitchen; broken drawer knob in residents' room; pieces of metal and pieces of wood, rusted grills, soiled placemat, empty milk container on the backyard ground
POC Due Date: 04/07/2026
Plan of Correction
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Administrator to do the following. Pictures to be submitted by 4/07/26:
(1) Stated she'll have the sink remove. (2) Replace the glass window. (3) Replace the drawer knob. (4) Clean the yard and stair.
A $250.00 civil penalty is assessed for repeat violation.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 03/24/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/24/2026 at 06:11 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(1)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning.

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 S3, a cook, not having food preparation training on file which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
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Administrator to have S3 trained and submit copy of training certificate.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in residents' (R1 and R2) LIC602A Physician's Report/medical assessments over a year old which pose a potential health, safety or personal rights risks to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
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Administrator to call the residents' doctor to schedule assessment and submit copies of LIC602A by 4/07/26.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 03/24/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/24/2026 at 06:11 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 not conducting the required drills at least every quarter which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
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2
3
4
Administrator to read the Regulation and self-certify that drills are conducted as required.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in not having doctor's orders for half bed rails for 2 residents which pose a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
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2
3
4
Administrator stated she'll obtain doctor's orders. Copies to be submitted by 4/07/26.
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 03/24/2026 07:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/24/2026 at 06:46 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 S2 not having LIC501 on file which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
1
2
3
4
Administrator to have the LIC501 completed and submit copy by 4/07/26.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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