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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200315
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:02:07 PM


Document Has Been Signed on 04/14/2022 04:02 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:MONTESSORI SENIOR RESIDENTIAL CAREFACILITY NUMBER:
079200315
ADMINISTRATOR:PAMELA ZELL RIGGFACILITY TYPE:
740
ADDRESS:3431 BALFOUR ROADTELEPHONE:
(925) 516-2111
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shakuntala Y. Chhagan, Assistant AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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On 4/14/2022 9:40AM, Licensing Program Analyst (LPA), L. Ibo conducted case management visit. While LPA was conducting investigation due to another visit, LPA found out that former resident (R1) fell and hit his face from a side table, this cause facial contusion or minor bruising. Based on the interview, staff failed to call 911 but informed R1’s family regarding the incident. After two days, R1 was taken to the emergency room by his family member.

Facility failed to send unusual incident report regarding the incident above.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.


Exit interview conducted with Assistant Adminsitrator, LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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 2


Document Has Been Signed on 04/14/2022 04:02 PM - It Cannot Be Edited

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: MONTESSORI SENIOR RESIDENTIAL CARE
FACILITY NUMBER: 079200315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited

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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...
This requirement was not met as evidenced by:
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Based on record review and interviews, Licensee did not comply with the regulation above. It was confirmed by multiple staff that staff did not immediately contact 911 when R1 fell and hit his head and side of his face which caused facial contusion or minor bruise which poses a health and safety risk to residents in care.
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Type B
04/22/2022
Section Cited

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(a)(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....(D) Any incident which threatens the welfare, safety or health of any resident.......
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This requirement is not met as evidenced by:
-Based on interview and records review, licensee did not comply with the above Regulation. Licensee did not submit incident reports to CCL when R1 fell and hit his side of his head which posed potential health, safety and personal rights risks to person in care.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2