079200607-1-26-2026-15-AS-JSAR-DQQ4DV-20260126180123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200607
Report Date: 01/26/2026
Date Signed: 01/26/2026 06:03:53 PM

Document Has Been Signed on 01/26/2026 06:03 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 III		FACILITY NUMBER:	079200607
ADMINISTRATOR/ DIRECTOR:	SIDDIGUI, SHAHID		FACILITY TYPE:	740
ADDRESS:	2870 FALCON CT		TELEPHONE:	(415) 637-4977
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 8		CENSUS: 5	DATE:	01/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Administrator Shahid Siddiqui		TIME VISIT/ INSPECTION COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/26/2026 at 2:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Required Annual Inspection. Upon entry, the LPA stated the purpose of the visit to Administrator Shahid Siddiqui. The LPA toured the facility, including but not limited to, residents’ rooms, bathrooms, kitchen, common areas and the backyard. The LPA observed adequate lighting for the comfort and safety of residents in all rooms. Inside and outside areas are free of obstruction and no bodies of water. The temperature in the dining room was measured at 75.3 degrees Fahrenheit. The residents’ bathrooms are equipped with grab bars and slip-resistant mats. There is more than the minimum of a one week supply of nonperishable foods and 2 days of perishable foods. The LPA observed the required postings in the facility. Smoke detectors and carbon monoxide detectors were tested and found to be in operating condition. The fire extinguisher was fully charged and serviced on 11/14/2025. Continued on LIC 809-C . . .

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 01/26/2026 06:03 PM - It Cannot Be Edited

Created By: James Sampair On 01/26/2026 at 05:12 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA III	FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The maximum hot water temperature was measured at 125.4 degrees Fahrenheit, which poses an immediate safety risk to persons in care.
	POC Due Date: 01/27/2026
	Plan of Correction
1 2 3 4	On or before due date, the Licensee shall send message to LPA Sampair that the max temperature is between 105 and 120 degrees Fahrenheit.

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Cabinet with cleaning products under kitchen sink not locked, which poses an immediate safety risk to persons in care.
	POC Due Date: 01/27/2026
	Plan of Correction
1 2 3 4	Cleared during 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.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2026 06:03 PM - It Cannot Be Edited

Created By: James Sampair On 01/26/2026 at 05:12 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA III	FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines 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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Centrally stored medication cabinet was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2026
	Plan of Correction
1 2 3 4	Cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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 Humpal
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 01/26/2026 06:03 PM - It Cannot Be Edited

Created By: James Sampair On 01/26/2026 at 05:12 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA III	FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. 4 of 30 cans checked beyond best buy date, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2026
	Plan of Correction
1 2 3 4	Cleared during visit.

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Cheese Whiz that had been opened was left in cabinet and not refrigerated, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2026
	Plan of Correction
1 2 3 4	Cleared during 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.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

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: 01/26/2026

NARRATIVE

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. . . Continued from LIC 809

The following citations were issued during the inspection:

Type A: Maximum hot water temperature was measured at 125.4 degrees Fahrenheit
Type A: Centrally stored medication cabinet was unlocked.
Type A: Cabinet with cleaning products under kitchen sink not locked.
Type B: 4 of 30 cans checked beyond best buy date
Type B: Cheese Whiz that had been opened was left in cabinet and not refrigerated.

The LPA reviewed 5 resident records and 5 staff records.

3 Type A and 2 Type B citations were issued during the inspection.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. 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.

The Required Annual Inspection is not complete. The LPA will return to complete it unannounced at a future date and time.

Exit interview conducted and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC809 (FAS) - (06/04)

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