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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 09/05/2024
Date Signed: 09/05/2024 05:53:28 PM


Document Has Been Signed on 09/05/2024 05:53 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: 70DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Diane Pederson/Executive DirectorTIME COMPLETED:
06:00 PM
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On this day, September 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Services Director Geraldine Tayo.

ED submitted an updated Infection Control Plan on September 28, 2023.

LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, activity room, library, kitchen, dining room. 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 staff. LPA randomly selected 12 residents apartments for inspection - 4 on the first floor, 4 on the second floor and 4 on the third floor.

Hot water temperature in one of the common bathrooms was tested and measured at 113.6 degrees Fahrenheit. Facility has carbon monoxide and smoke detectors that were observed in working condition. Fire extinguisher in the kitchen checked, observed fully charge with tag showed serviced January 11, 2024. Facility has evacuation chairs on stairwells. Facility conducts disaster drills at least every quarter, and records showed last conducted June 11, 2024.

LPA reviewed 5 staff and 5 resident's files. 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 n809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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
VISIT DATE: 09/05/2024
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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

No deficiency cited during today inspection.

Exit interview conducted, 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: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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