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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 10/13/2021
Date Signed: 10/13/2021 06:10:55 PM

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:DIANE PEDERSONFACILITY TYPE:
740
ADDRESS:21000 MISSION BLVD.TELEPHONE:
(510) 276-2872
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:140CENSUS: 75DATE:
10/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Executive Director Diane Pederson TIME COMPLETED:
06:15 PM
NARRATIVE
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During investigation of complaint (Control # 15-AS-20190926095603) and upon review of resident's (R1) file and review of facility file at Community Care Licensing (CCL) office, Licensing Program Analyst (LPA) Delmundo learned that resident (R1) who has dementia does not have medical assessments for 2018 and 2019. Facility does not have Dementia Care Plan nor have submitted this plan to CCL. These were discussed with Diane Pederson during one of visits when LPA was conducting investigation.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with Diane Pederson.

Exit interview conducted. Appeal Rights, 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: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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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: LANDMARK VILLA
FACILITY NUMBER: 015601501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment ....and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s......
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-This requirement is not met as evidenced by:

-Based on records review, the licensee did not comply with the section above. R1 who has dementia didn't have medical assessments for 2018 and 2019 which posed potential health and safety risks to person in care.
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Type B
10/27/2021
Section Cited

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87208 Plan of Operation
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

--This requirement is not met as evidenced by:
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-Based on records review, the licensee did not comply with the section above by retaining R1 who has dementia when facility does not have Dementia Care Plan nor submit an addendum tothe Plan of Operation which poses potential health and safety 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021
LIC809 (FAS) - (06/04)
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