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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200607
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:12:37 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
02/17/2023 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20230217095005
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: 6DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:SIDDIGUI, SHAHID, Administrator TIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility staff are not following reporting requirements
INVESTIGATION FINDINGS:
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On 5/3/2023 at around 1:40AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met Administrator Shahid Siddigui, LPA informed him the purpose of the visit.

Based on interview and records review, Licensee failed to notify licensing regarding an incident happened on 4/26/2023. Interview revealed that, resident (R5) had an unusual incident report on 4/26/2023, Administrator claims that incident report was sent via email, but LPA could not find proof of the report. Administrator admitted he did not call CCL to report regarding the incident.

The preponderance of evidence has been met. Therefore, the allegations above are substantiated.

...CONTINUED TO LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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 5
Control Number 15-AS-20230217095005
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: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607
VISIT DATE: 05/03/2023
NARRATIVE
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Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230217095005
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: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited
CCR
87211(a)(2)
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(a)Each licensee shall furnish to the licensing agency such reports...including, but not limited to, the following: (2) Occurrences, such as...which threaten the welfare, safety or health of residents....
This requirement is not met as evidenced by…
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Administrator agrees to review regulation and submit a self-certification to be in compliance in future events to CCL by the POC due date.
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Based on interview the licensee did not comply with the section cited above. Facility failed to report incident to CCL when incident occurred which poses a potential health, safety or personal rights 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: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/17/2023 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20230217095005

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: 6DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:SIDDIGUI, SHAHID, Administrator TIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility does not have an adequate amount of food
Facility staff do not ensure that residents are adequately fed
Facility staff are not adequately trained to meet the needs of residents in care
Insufficient staffing
INVESTIGATION FINDINGS:
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On 5/3/2023 at around 1:40PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator SIDDIGUI, SHAHID , LPA explained the purpose of the visit.

Allegation: Facility does not have an adequate amount of food

Based on LPA’s observation, facility has sufficient amount of food. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Based on staff interview, the Administrator buys grocery at least once a week.

...CONTINUE LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230217095005
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: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607
VISIT DATE: 05/03/2023
NARRATIVE
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Allegation: Facility staff do not ensure that residents are adequately fed

Based on staff and residents’ interview, facility provides three meals a day and snacks in between meals. Based on records review, there were no resident with significant lost weight due to insufficient food.

Allegation: Facility staff are not adequately trained to meet the needs of residents in care

Based on staff interview and records review, facility conducts the yearly training to follow training regulation. Based on interview with Administrator, he provides training with staff during staff training if there is anything that’s needed to be discuss with staff.

Allegation: Insufficient staffing

LPA reviewed staff schedule for the facility, two caregivers available on morning to PM shift and one awake caregiver for night shift . Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with residents and residents reported that they are happy living at the facility and had no issues around staff availability to meet their needs. Residents that were interviewed reported that facility staff attend to their needs.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.



Exit interview conducted and a copy of this report provided to Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5