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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200607
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:19:02 PM

Document Has Been Signed on 01/24/2025 03:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SPYGLASS SENIOR VILLA IIIFACILITY NUMBER:
079200607
ADMINISTRATOR/
DIRECTOR:		SIDDIGUI, SHAHIDFACILITY TYPE:
740
ADDRESS:2870 FALCON CTTELEPHONE:
(415) 637-4977
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Gilbert Villota, CargiverTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 01/24/2025 at 10:25AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Gilbert, Villota spoke with Administrator, Shahid Siddiqui via telephone, and explained the purpose of the visit. The Administrator currently holds a certificate (#6043867740) that expires on 03/15/2025. The facility’s fire clearance was approved for eight (8) non-ambulatory residents. Administrator had to leave during visit and gave authorization to Gilbert Villota, Caregiver to sign reports.

LPA toured the facility with Caregiver, Gilbert Villota including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and four (4) bathrooms. one (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/14/2024. Emergency Disaster Plan was last posted on 02/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 09/14/2019.


Continue on LIC809C
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641
DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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Document Has Been Signed on 01/24/2025 03:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or..

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not comply with the section cited above by not associating S1 to the facility which poses a potential health and safety risk to the persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to associate S4 and send a self- certifying email to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(3)
87608(a)(3) Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order

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 in having five (5) out five (5) residents in hospital beds with bed rails without orders which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to obtain orders for hospital beds with bed rails and send CCLD an email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607
VISIT DATE: 01/24/2025
NARRATIVE
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Continued from LIC809.

Four (4) staff records were reviewed, three (3) staff members were missing annual training, S4 wasn't associated and was missing Health Screening . LPA reviewed all five (5) resident records, and they were incomplete.

LPA requested the following documents to be submitted to CCLD by 01/31/2025.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance

LPA observed the following deficiencies:
  • At 11:20AM, LPA observed all five residents has hospital beds with bed rails
  • At 12:15PM, LPA observed during file review all five residents files were incomplete
  • At 12:30PM, LPA observed during file review three (3) out of four (4) staff did not have annual training and S4 was missing Health Screening and was not associated to the facility

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted a copy of this report, appeal rights and LIC412FC provided

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/24/2025 03:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87411(c)
87411 Personnel Requirements – General

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having three (3) staff members complete annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to have staff complete annual training and send a self certifying email to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having S4 health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to have S4 obtain a health screening and send CCLD an email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025

LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/24/2025 03:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SPYGLASS SENIOR VILLA III
FACILITY NUMBER: 079200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87506(b)
87506 Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having 5 out of 5 resident records being incomplete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agrees to update and complete all resident records by POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025

LIC809 (FAS) - (06/04)
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