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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601501
Report Date: 03/19/2026
Date Signed: 03/19/2026 05:33:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2026 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20260311122815
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: 74DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Geraldine Tayo/Interim Administrator TIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff do not allow residents to participate in decision making regarding care provided.
Staff did not communicate with responsible parties regarding residents' care.
INVESTIGATION FINDINGS:
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On this day, March 19, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Geraldine Tayo, interim administrator (IADM), and informed the reason for visit.

LPA obtained copies of resident roster and staff schedule. LPA reviewed residents records and obtained copies of LIC601 Identification and Emergency Contact Information and LIC602A Physician's Reports. LPA interviewed Prema Thekkek (licensee), staff (IADM and S1), resident's family member (FM) and residents (R1, R2, R3).


....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20260311122815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/19/2026
NARRATIVE
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Allegation: Staff do not allow residents to participate in decision making regarding care provided.
Allegation: Staff did not communicate with responsible parties regarding residents' care.
The reporting party stated that the licensee had a doctor (DR) came to the facility on February 2026 and provided care to residents (R1, R2, R3, R4, R5) and that DR ordered physical therapy (PT) for the residents, however, the residents have their own physicians and the residents' responsible parties were not consulted prior to DR providing care.

The licensee stated she remembers about DR coming to the facility, because the residents' LIC602A Physician's Reports need to be updated in order to be in compliance and residents needing assessment due to falls. The licensee further stated that her understanding was Geraldine Tayo (IADM) and another staff had contacted the residents' family members.

Review of R1, R2, R3, R4 and R5 records showed these residents have their primary care physician, not DR. One of the resident's responsible person, FM, stated not getting a call from the facility about a different doctor checking on the resident. R1 and R2 indicated being seen by a different doctor and that they were not given prior notice. Records also showed R1 and R2 are seen by PT.

IADM confirmed that DR came on the said date and an instruction were disseminate to the facility staff by staff (SS) night prior. Both IADM and S1 stated they were not able to call the residents' family members nor informed the residents that a different doctor is coming for assessment due to information was sent late night and that DR came the following day. Review of document confirmed both S1 and IADM's statements regarding the time the information was disseminated. Document also showed there was no instruction from SS to contact the residents' responsible persons nor inform the residents. Document also showed SS asking the staff for copies of LIC602 and insurance and to have them ready by 9:30 am on the day DR is coming.

Based on records review and interviews, the preponderance of evidence standard is met, therefore the 2 allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with IADM, Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260311122815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2026
Section Cited
HSC
1569.269(a)(20)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (20) To select their own physicians, pharmacies, privately paid personal assistants, hospice agency, and health care providers.......
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Licensee and IADM to read the Regulation and self certify compliance. Proof to be submitted by 4/02/26.
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-This requirement is not met as evidenced by:
- Based on records review and interviews, the licensee did not comply with the section above in having the residents seen by different doctor without consent from the residents and resident's responsible person which pose a potential personal rights risks to persons in care.
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Type B
04/02/2026
Section Cited
HSC
1569.269(a)(9)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (9) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding the care and services
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Licensee and IADM to read the Regulation and ensure compliance. Self-certification to be submitted by 4/02/26.
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-This requirement is not met as evidenced by:
- Based on records review and interviews, the licensee did not comply with the section above in not having the residents and resident's responsible person participate regarding residents' care which pose a potential rights risk to persons 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 Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3