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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200607
Report Date: 03/26/2024
Date Signed: 03/26/2024 10:57:50 AM

Unsubstantiated


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
03/20/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240320125332
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: 5DATE:
03/26/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Alice Fontela, CaregiverTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Staff did not keep resident's door free from obstruction.
INVESTIGATION FINDINGS:
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On 3/26/2024 10:10am, Licensing Program Analysts (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the above allegations. LPAs met with Alice Fontela, Caregiver and explained the reason for the visit. Administrator, Shahid Siddigui, arrived at 10:48am.

During the visit LPAs toured facility, obtained and reviewed staff schedule and resident roster. During tour LPAs did not observe any doors leading to bedrooms or exterior doors blocked.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
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 2
Control Number 15-AS-20240320125332
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: 03/26/2024
NARRATIVE
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Continued from LIC9099.

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

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2