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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601506
Report Date: 02/14/2025
Date Signed: 02/14/2025 05:39:19 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
02/07/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250207120824
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: 13DATE:
02/14/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mirriam Paras/AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility is unsanitary.
INVESTIGATION FINDINGS:
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On this day, 2/14/25, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation, and met with staff, Jonalyn Legarto, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM), who arrived at around 12:10 pm.

LPA conducted inspection with Jonalyn Legarto and observed the following: strong smell of urine in the big bathroom; mouse droppings in the area adjacent to the kitchen; stain and dusty floor in the dining room where the 2 refrigerators are located; dusty air vents.

Based on observation, the preponderance of evidence standard is met, therefore, the allegation is substantiated.

....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
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-20250207120824
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: 02/14/2025
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation within 12 month of section 87303(a). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency, plan and proof of correction, and civil penalty were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250207120824
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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87303(a)
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87303 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.
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Staff cleaned and removed the mouse droppings.
In addition, administrator to do the following and submit proof by 2/28/25:
1. Have the bathrooms cleaned thoroughly.
2. Have all the vents and flooring cleaned properly.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above for the following which pose a potential health and/or personal rights risks to persons in care: strong smell of urine in the bathroom; mouse droppings; dusty air vents; stain and dusty floor
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A $250.00 civil penalty is assessed for repeat violation. A citation was issued on 9/04/24.
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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: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3