<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 03/08/2024
Date Signed: 03/08/2024 08:14:02 PM


Document Has Been Signed on 03/08/2024 08:14 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:MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:22107 MONTGOMERY STREETTELEPHONE:
(510) 889-8556
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 15DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Staff, Jonalyn Legarto
and Medelmira Cloma 		TIME COMPLETED:
08:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, March 8, 2024, at 10:45 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Jonalyn Legarto
and Medelmira Cloma. 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.

Facility has LIC808 Mitigation Plan. Administrator submitted the LIC9282 Infection Control Plan on March 5, 2024.

LPA toured the facility inside out with Jonalyn Legarto. Facility is a two level home. 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 observed locked.

Hot water temperature in one of the bathrooms on the ground floor was tested. Fire extinguisher was observed fully charge with tag showed serviced 9/22/23.

LPA interviewed 2 residents.

LPA observed the following:
-at 11:15 a.m., staff medications and vitamins, scissors and disinfecting spray in area adjacent to the kitchen.
-at 11:21 a.m., cleaning agents in kitchen cabinet under the sink without lock.
-at 11:23 a.m, rubbing alcohol, medications and scissors in resident's room. Razors in the ensuite bathroom in this resident's room.
.continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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.

LIC809 (FAS) - (06/04)
Page: 1 of 8


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: 03/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUATION:
-at 11:34 a.m., Icy Hot pain reliever ointment in another resident's room on the ground floor.
-at 11:35 a.m., Lysol toilet bowl cleaner in the common bathroom on the ground floor. Toilet paper holder in this bathroom broken and door paint dilapidated.
-at 11:42 a.m., Tums, motor oil for shredder in another resident's room. Trash can in this room and rooms on the second floor without lids.
-at 11:46 a.m., toilet paper holder in another common bathroom on the first floor broken, dilapidated door paint and rotten wood transition on the flooring.
- at 11:49 a.m., storage on the second floor converted into staff's room.
-at 11:50 a.m., mildew on the shower door in second floor bathroom.
- at 11:52 a.m., bread toaster. Hydrogen Peroxide and medications i n one of resident's room on the second floor.
-no auditory signals on the exit doors of 2 residents rooms.
-at 12:01 p.m., staff clothing, personal belongings, medications and scissors in other residents' room on the second. Two staff were interviewed who stated staff sleeps and use the resident's bed.
-at 12:19 p.m., tools in unlocked tool cart. bleach, shovel, pieces of wood, Pine Sol cleaning agent in the backyard.
-at 12:34 p.m., hot water temperature in one of the common bathroom was measured at 137.8 degrees Farenheit.
-at 2:50 p.m., cleaning supplies, pails of paint and pieces of wood in the side yard.
-no disaster drill on file. LPA interviewed 2 staff and administrator who all stated they don't do disaster drill.

Deficiencies are cited from Title 22 California Code of Regulations, and cited on 809Ds. A $500.00 civil penalty is assessed for fire safety violation in converting the storage into staff bedroom, and will continue for $100.00/day until corrected.

Deficiencies, plan and proof of corrections and civil penalty was discussed with administrator over the phone.

Due to time constraint, LPA will come back to continue inspection.

Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 03/08/2024 08:14 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care.

At $500.00 civil penaty is assessed.
POC Due Date: 03/09/2024
Plan of Correction
1
2
3
4
Administrator stated she'll have the room converted to it's original use as storage. Picture to be submitted by 3/09/24.
Type A
Section Cited
CCR
87303(i)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:

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 2 exit doors with no auditory signals which pose an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
1
2
3
4
Administrator to have signals installed, and submit pictures by 3/09/24.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 03/08/2024 08:14 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
1
2
3
4
Staff removed the items.
In addition, administrator to in-service the staff, and submit proof by 3/09/24.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
1
2
3
4
Staff locked the items..
In addition, administrator to in-service the staff, and submit training topic with attendees signatures.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 03/08/2024 08:14 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 personal rights risks to persons in care: toilet paper holder in 2 bathrooms broken; 2 bathroom doors with dilapidated paint; wood transition in bathroom flooring rotten.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Administrator to do the following, and submit pictures by 3/22/24:
1. Replace the toilet paper holder.
2. Repaint the bathroom doors.
3. Replace the wood transition.
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

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 trash cans in residents' rooms with no lids which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Administrator to purchase trash bins with foot pedal operated lids, and submit proof of purchase and pictures by 3/22/24.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 03/08/2024 08:14 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

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

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 interviews, the licensee did not comply with the section cited above in not conducting drills which poses a potential safety risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Administrator to have drills conducted, and submit proof by 3/22/24.
Type B
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

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 not having evacuation chair which poses potential safety risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Administrator to purchase evacuation chair, and submit proof of purchase by 3/22/24.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 03/08/2024 08:14 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 hot water at 137.8 degrees Fahrenheit.
which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
1
2
3
4
Administrator to have the temperature adjusted within Regulations range, and submit proof by 3/09/24.
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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 8 of 8


Document Has Been Signed on 03/08/2024 08:14 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: MONTGOMERY SPRINGS MANOR
FACILITY NUMBER: 015601506

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in staff sleeping in the resident's room which poses a potential personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Administrator to have the staff stop sleeping in resident's room immediately.
In addition, administrator to in-service the staff, and submit proof by 3/22/24.
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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
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
LIC809 (FAS) - (06/04)
Page: 7 of 8