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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601501
Report Date: 08/07/2026
Date Signed: 08/07/2026 03:06:14 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
08/05/2026 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20260805130538
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: DATE:
08/07/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff does not ensure carpets on the stairs are clean.
INVESTIGATION FINDINGS:
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On this day, 08/07/2026, at 12:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unnounced to investigate the above allegation. LPA met with Assisted Living Director (ALD) Leonora Ramos and Maintenance Director (MD) Sixo Antolin and informed the reason for visit.

It was reported that facility staff regularly shampoo the carpets in the common areas to keep them clean and deodorized, but they do not shampoo the carpet on the staircases. The reporting party (RP) stated there is a terrible odor coming from the filthy carpets on the stairs.


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

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
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-20260805130538
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: 08/07/2026
NARRATIVE
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During investigation, LPA obtained copy of LIC500 Personnel Report and interviewed the Maintenance Director (MD). LPA inspected the 5 stairwells and the stair going to the parking garage with Assisted Living Director (ALD) and MD. All 5 stairwells and stair were observed with heavily soiled carpets. LPA also observed dried leaves on one of the stairwells and some of the edges of the stairs with black tape.Two of the 5 stairwells were also observed with dilapidated carpet. Therefore, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulation and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed over the phone with Executive Director (ED) Geraldine Tayo in the presence of the MD and ALD. The ED authorized ALD to sign and receive this report.

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: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260805130538
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: 08/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) 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.
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Executive Director (ED) stated she'll have the stairwells deep cleaned as a quick fix. In addition, ED stated she will talk to the licensees and will have carpets replaced. Proof to be submitted by 09/04/2026.
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-This requirement is not met as evidenced by:
-Based on interview and observation, the licensee did not comply with the section in heavily soiled and dilapidated carpet on stairwells which pose a potential health, safety and/or personal rights risks 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: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3