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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200607
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:33:09 PM


Document Has Been Signed on 02/23/2023 01:33 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:SPYGLASS SENIOR VILLA IIIFACILITY NUMBER:
079200607
ADMINISTRATOR:SIDDIGUI, SHAHIDFACILITY TYPE:
740
ADDRESS:2870 FALCON CTTELEPHONE:
(415) 637-4977
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:8CENSUS: 7DATE:
02/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:SIDDIGUI, SHAHID, Administrator TIME COMPLETED:
01:50 PM
NARRATIVE
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On 02/23/2023, while conducting another inspection visit, Licensing Program Analyst (LPA) Leslie Ibo
conducted unannounced Case Management inspection.

During LPA's facility tour the following was observed:

At 9:44AM disinfectant and cleaning products was accessible to residents in care. Corrected during the visit.
At 9:40AM medication was observed at the counter, which was accessible to residents in care.
At 10:00AM during records review it was revealed that R2 & R3 are bedridden residents at the facility and facility do not have bedridden fire clearance.

The following deficiencies was observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

A $500.00 civil penalty is being assessed today.



Exit interview conducted. Appeal Rights and a copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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


Document Has Been Signed on 02/23/2023 01:33 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: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited

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Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons...(2) Bedridden persons
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Administrator/Licensee agreed to notify the fire department within 24 hours that R2 & R3 are bedridden, shall submit to licensing an LIC200, updated facility sketch, along with a request for a fire inspection to retain a bedridden resident at facility by POC date (02/24/2023)
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Based on observation and interviews, Licensee failed to obtain fire clearance for two (2) (R2 & R3) bedridden residents. LPA observed and records review revealed that R2 & R3 is bedridden. However, facility does not have bedridden clearance which poses an immediate health and safety risk to residents in care.
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A civil penalty of $500.00, is being assessed today.
Type A
02/24/2023
Section Cited

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(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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S3 locked the medication. Administrator agreed to conduct in-service training with all the staff. Proof of training with staff names, signature and copy of training topic needs to be submitted to CCL by 02/27/2023.
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to persons in care.
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Corrected during the visit.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/23/2023 01:33 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: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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S3 locked the medication. Administrator agreed to conduct in-service training with all the staff. Proof of training with staff names, signature and copy of training topic needs to be submitted to CCL by 02/27/2023.
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Based on observation, the licensee did not comply with the section cited above by having unlocked disinfectants and cleaning products in the which poses an immediate health and safety 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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