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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601506
Report Date: 05/01/2024
Date Signed: 05/01/2024 01:46:32 PM


Document Has Been Signed on 05/01/2024 01:46 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: 11DATE:
05/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jonalyn Legarto/StaffTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Jonalyn Legarto, staff, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator, who authorized to sign and receive this report.

On 4/26/24, LPA continued the annual inspection and issued citation section 87705(c)(1) for having residents (R3 and R4) in bedrooms not fire cleared for non-ambulatory. For plan of correction, the administrator stated she'll have the residents move-out. The administrator submitted the POC;however, the POC didn't indicate when the residents moved-out.

On this day, 5/01/24, LPA toured the facility with staff (S1). and didn't observed R3 and R4. LPA interviewed S1 who confirmed R3 and R4 were moved-out. Deficiency is cleared.

Exit interview conducted, 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: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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