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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:55:50 PM

Document Has Been Signed on 01/23/2025 03:55 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:LANDMARK VILLAFACILITY NUMBER:
015601501
ADMINISTRATOR/
DIRECTOR:		DIANE PEDERSONFACILITY TYPE:
740
ADDRESS:21000 MISSION BLVD.TELEPHONE:
(510) 276-2872
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 140TOTAL ENROLLED CHILDREN: 0CENSUS: 75DATE:
01/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Diane Pederson/Executive Director TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At 12:30 pm on this day, 1/23/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on 1/20/25. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Care Director Geraldine Tayo.

UIR indicated that on 1/19/25 at approximately 5:00 am, staff (S2) stated she witnessed the caregiver (S1) physically and verbally handling resident (R1) roughly. S1 was removed from schedule and the ED notified R1's daughter, Ombudsman and Community Care Licensing. Investigation was conducted and S1 was terminated.

LPA reviewed R1's file and conducted interviews. LPA obtained copies of resident roster, staff schedule, facility staff's statements, and including but not limited to the following R1's documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal and Re-appraisal

No deficiency cited on this day.

Exit interview conducted and copy of this report provided.

Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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