015601506-3-8-2024-15-AS-KHOS-D84Q66-20240813115301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 03/08/2024
Date Signed: 03/08/2024 08:10:08 PM

Substantiated

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
03/08/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240308084431

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: 15	DATE:	03/08/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Staff, Jonalyn Legarto and Medelmira Cloma		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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-Staff made inappropriate comments towards resident.

-Staff did not prevent resident from engaging in inappropriate behaviors

INVESTIGATION FINDINGS:

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At 10:45 am on this day, 3/08/24, Licensing Program Analyst (LPA Delmundo arrived unannounced to investigate the above allegations. LPA met with staff, Jonalyn Legarto and Medelmira Cloma, and informed the reason for visit. LPA called and spoke with Mirriam Paras, administrator, who stated she can not come to the facility, and authorized Jonalyn Legarto to sign and receive this report.

During investigation, LPA interviewed four (4) staff and 2 residents, and reviewed residents record and obtained copies of documents. LPA were not able to interview other residents either due to their diagnosis or not at the facility. LPA also made observation.

....continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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-20240308084431

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: 03/08/2024

NARRATIVE

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Allegation: Staff made inappropriate comments towards resident.
It was alleged that staff (S1) tells R1 "that's your problem" and call R1 "bitch". Although 4 of the staff stated it was R1 who always say "bitch" to the staff and other residents, S1 admitted to telling R1 "it's your problem if you don't ignore e R1" when R1 called S1 when R2 was bothering R1.

Allegation: Staff did not prevent resident from engaging in inappropriate behaviors.
It was alleged that R2 keeps on following resident (R1) around and barging into residents rooms and staff is not doing anything. It was further alleged that R1 was upset due to staff sitting R2 next to R1 in the dining table.

Four of the staff stated R2 has wandering behavior. One of the two residents interviewed stated staff do nothing to get R2 out of his room while the other one stated the staff yells at R2 to have R2 go out from the residents' room but most of the time, do nothing at all and R1 gets agitated when R2 goes to R1's room. Review of R2's record showed R1 has wandering behavior which LPA observed R2 wandering and going in and out of residents' rooms, kitchen, dining and hallways the whole time LPA was conducting investigation. LPA further observed and upon interview learned that there's only caregiver on duty from 6:00 a.m. to 3:00 p.m., and 1 caregiver from 3:00 p.m. to 11:30 p.m. and most of the time not able to redirect R2 right away when R2 goes to residents' rooms.

Based on the information obtained, the preponderance of evidence has been met, therefore the allegations of "Staff made inappropriate comments towards resident" and "Staff did not prevent resident from engaging in inappropriate behaviors." are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 9099Ds. 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 Mirriam Paras over the phone.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20240308084431

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/22/2024 Section Cited CCR 1569.269(a)(1)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to in-service the staff, and submit proof by 3/22/24.
	8 9 10 11 12 13 14	-Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care.	8 9 10 11 12 13 14
Type B 03/22/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs........ -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated she'll hire additional staff. Copy of staff schedule to be submitted by 3/22/24.
	8 9 10 11 12 13 14	-Based on interviews, observation and records review, the licensee did not comply to the section above in not having sufficient staffing to be able to redirect resident timely and properly which poses potential personal rights risks to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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
03/08/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240308084431

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: 15	DATE:	03/08/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Staff, Jonalyn Legarto and Medelmira Cloma		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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-Staff are not meeting resident's medical needs

-Staff are not providing a comfortable environment for resident.

-Staff did not ensure facility furniture was clean

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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-20240308084431

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: 03/08/2024

NARRATIVE

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All 3 staff interviewed stated they check R1's blood pressure when requested and record the reading, All 3 staff confirms R1's roommate (R5) screams when being changed; however, they try to calm R5 down. LPA was unable to interview R5. There was record of R1's blood pressure but only for 1 day.

Allegation: Staff are not providing a comfortable environment for resident.
R1 stated that her room is cold at night. All 3 staff interviewed stated that R1 complained about R1's room being cold. Facility has centralized heater but when R1 complained about the room being cold, R1 was provided a portable heater. LPA observed a portable heater in R1's room and the room's windows with coverings/curtains. LPA also checked the room temperature at around 4:00 pm which was measured at 68.7 degrees Fahrenheit. LPA was not able to obtain information from R1's roommate. Two other residents were interviewed who stated the temperature is at comfortable level.

Allegation: Staff did not ensure facility furniture was clean.
It was alleged that chairs in the living room are not clean.
LPA interviewed 4 staff who stated the chairs and couches in the living room have covers and at times get soiled when residents spill food or have accidents but when these happen, they removed and wash the covers. LPA conducted inspection and didn't observed any being soiled or dirty,

Based on information obtained and LPA unable to obtain information from R1's roommate, all 3 allegations are closed as 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: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC9099 (FAS) - (06/04)

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