015601501-9-30-2026-15-AS-ADEO-DYF4FK-20260930190403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 09/30/2026
Date Signed: 09/30/2026 07:04:20 PM

Document Has Been Signed on 09/30/2026 07:04 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 VILLA		FACILITY NUMBER:	015601501
ADMINISTRATOR/ DIRECTOR:	DIANE PEDERSON		FACILITY TYPE:	740
ADDRESS:	21000 MISSION BLVD.		TELEPHONE:	(510) 276-2872
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 140		CENSUS: 69	DATE:	09/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:55 AM
MET WITH:	Geraldine Tayo/Executive Director		TIME VISIT/ INSPECTION COMPLETED:	07:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, 09/30/2026, at 11:55 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Geraldine Tayo and informed the reason for visit. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, kitchen, dining room, yard, ensuite bathrooms, courtyard, library/activity area, laundry room and two of the stairwells. Food supplies were observed adequate for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily, and records showed temperatures were within Regulations range. LPA randomly selected 6 residents apartments for inspection - 2 on the first floor, 2 on the second floor and 2 on the third floor. Hot water temperature in one of the resident's apartments was tested and measured at 111.2 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced 01/07/2026. Facility conducts disaster drills and records showed last conducted on 3/13/26, 5/19/26 and 6/06/26. LPA reviewed 5 staff and 5 resident's records, and interviewed 2 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....continued on 809C

Bennett Fong
Alicia Delmundo
	DATE: 09/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
	VISIT DATE: 09/30/2026

NARRATIVE

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LPA received the following updated/current documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

LPA observed the following and were cited from Title 22 California Code of Regulations and listed on
809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

from 3:45 pm to 4:30 pm, staff, S2 and S4 have no TB test and LIC503 Health Screening, S2 has no food service training records on file; S5 has no LIC503 Health Screening on file.
staff, S2, has no food service training on file.

Deficiencies and plan and proof of corrections were discussed with the Executive Director.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2026 07:04 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 09/30/2026 at 06:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LANDMARK VILLA	FACILITY NUMBER: 015601501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in S2 and S4 not havingTB test on file. which pose potential health, safety and/or personal rights risk to persons in care.
	POC Due Date: 10/14/2026
	Plan of Correction
1 2 3 4	Executive Director to have the staff TB tested and submit copies of test results by 10/14/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2026 07:04 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 09/30/2026 at 06:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LANDMARK VILLA	FACILITY NUMBER: 015601501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having LIC503 Health Screening records on file which pose a potential health and/or personal rights risks to persons in care.
	POC Due Date: 10/14/2026
	Plan of Correction
1 2 3 4	Executive Director to have the staff undergo health screening and submit copies of LIC503s by 10/14/26.

Type B

Section Cited

CCR

87555(b)(17)

General Food Service Requirements

(17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S2 not having record of formal food service training nor facility has record of consults with a nutritionist, dietician or home economist which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 10/14/2026
	Plan of Correction
1 2 3 4	Executive Director stated they will seek consult with a dietician. Proof to be submitted by 10/14/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026

LIC809 (FAS) - (06/04)

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