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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 09/28/2023
Date Signed: 09/28/2023 07:43:44 PM


Document Has Been Signed on 09/28/2023 07:43 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:DIANE PEDERSONFACILITY TYPE:
740
ADDRESS:21000 MISSION BLVD.TELEPHONE:
(510) 276-2872
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:140CENSUS: 80DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Diane Pederson/Executive Director and
Geraldine Tayo/Resident Services Director		TIME COMPLETED:
07:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit. LPA also met with Resident Services Director Geraldine Tayo.

Facility has an approved LIC808 Mitigation Plan but has not submitted the updated Infection Control Plan.

LPA toured the facility inside out with Diane Pederson, Facility is a 3 story building. LPA inspected the common areas, activity room, library, kitchen, dining room and yard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily. Medication room was observed attended by 3 staff. LPA randomly selected 8 residents rooms for inspection - 2 on the first floor, 2 on the second floor and 4 on the third floor.

Facility has carbon monoxide and smoke detectors. Hot water temperature in one of the common bathrooms was tested and measured at 113.6 degrees Fahrenheit. Fire extinguisher in the kitchen checked, observed fully charge with tag showed serviced December 28, 2022. Facility has evacuation chairs on stairwells. Facility conducts disaster drills every quarter.

LPA reviewed 5 staff and 5 resident's files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle resident's cash resources/P&I.

At 12:36 pm, LPA observed chest rub in resident's (R1) room.

.....continued on n809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 09/28/2023
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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
5. Infection Control Plan

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with the ED.

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: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/28/2023 07:43 PM - It Cannot Be Edited

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: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above fpr unlocked chest rub in resident's room which poses an immediate health and safety risks to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Staff locked the iitems.
In addition, ED to conduct in-service training and submit copy of training topic with attendees signature by 9/29//23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3