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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200607
Report Date: 01/28/2026
Date Signed: 01/28/2026 06:51:08 PM

Document Has Been Signed on 01/28/2026 06:51 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: 8CENSUS: 5DATE:
01/28/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator Shahid SiddiquiTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On 1/28/2026 at 10:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Case Management Annual Continuation Inspection. Upon entry, the LPA stated the purpose of the visit to Caregiver Jake Lapuz, shortly thereafter the LPA spoke with Administrator Shahid Siddiqui by phone.

The LPA reviewed facility documents, 5 resident records, and 5 staff records.

14 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 complete.

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: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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 10
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)
Page: 2 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. No Plan of Operation at facility, so no description of the ways in which the Licensee will address resident behavioral expression as defined in Section 87101 and no infection control plan LIC 9282 at facility, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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On or before the due date the Licensee will attest to LPA Sampair that the Plan of Operation is at the facility and that he has shown staff where it is located and that it is now part of new staff training to show them where it is located.
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, the licensee did not comply with the section cited above with a staff shortage for more than two weeks, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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On or before the due date the Licensee will attest to LPA Sampair that he has reviewed Section 87413 of Title 22.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Shahid Siddiqui is not conducting administrative duties at the facility a minimum of 20 hours per week during normal working hours, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
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On or before the due date the Licensee shall have an administrator conducting administrative duties at the facility a minimum of 20 hours per week during normal working hours.
Type B
Section Cited
CCR
87412(e)
Personnel Records
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.

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. The posted LIC 500 has hours for Administrator who is not at the facility during those times and prospective caregiver who has not yet been cleared to care for residents, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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On or before the due date the Licensee will create an accurate LIC 500 and send it to LPA Sampair via email.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above. 0 of 2 staff completed 20 hours of training. Medication training is a separate requirement and is not included in the 20 hours, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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On or before the due date the Licensee will send documentation to LPA Sampair that both of the staff members have completed 20 hours of training.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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. 1 staff assisting residents with medication never had medication training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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On or before the due date the Licensee will have the staff member complete the medication training and send via email proof to LPA Sampair.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in 5 out of 5 residents, which poses a potential health risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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2
3
4
On or before the due date, Licensee shall carefully review Section 87219 of Title 22 and attest to LPA Sampair by email that they have reviewed it.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above. A majority of the required resident documents are missing: LIC 621 2 of 5 missing, LIC 601 5 of 5 missing, LIC 627C 5 of 5 missing, and LIC 613C-2 2 of 5 missing, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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On or before the due date, Licensee will get signed, dated, and completed documents LIC 621, LIC 601, LIC 627C, and LIC 613C-2. The Licensee will attest to LPA Sampair by email that those have been retained or promises from families have been made to send them by the end of February.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents by using the wrong form. He needs to use LIC 603A RESIDENT APPRAISAL and LIC 9172 FUNCTIONAL CAPABILITY ASSESSMENT instead to conduct Pre-Admission Appraisals, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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2
3
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On or before the due date, Licensee shall carefully review Section 87456 and 87457 of Title 22 and attest to LPA Sampair by email that he has reviewed it.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. 2 of 3 residents living at facility more than 12 months did not have their annual reappraisal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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2
3
4
On or before the due date, the Licensee shall complete the annual Appraisal, Needs, and Services form for all of the residents in need, and attest to LPA Sampair by email that they have reviewed it.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. 2 of 3 residents living at facility more than 12 months did not have their annual routine visits, which poses a potential health risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
1
2
3
4
On or before the due date, the Licensee shall schedule all of the residents in need for their annual routine visit, and attest to LPA Sampair by email that the appointments have been scheduled as soon as possible.
Type B
Section Cited
CCR
87507(l)
Admission Agreements
(l) The licensee shall attach a copy of applicable resident's rights specified by law or regulation to all admission agreements, and shall include information on the reporting of suspected or known elder and dependent abuse, as set forth in Health and Safety Code Section 1569.889.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above.2 of the 5 resident files had no Personal Rights (LIC 613C) in them, which poses a potential personal rights risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
1
2
3
4
On or before the due date, the Licensee shall get completed, signed and dated LIC 613Cs for every resident where they are missing and attest to LPA Sampair by email that they have been collected for those residents.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2025, which poses a potential safety risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
1
2
3
4
On or before the due date, the Licensee shall complete the quarterly drill with all staff members and schedule the future drills for 2026 and beyond and provide proof to LPA Sampair by email.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 01/28/2026 06:51 PM - It Cannot Be Edited


Created By: James Sampair On 01/28/2026 at 05:27 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: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 in no physician's orders for 2 of the 5 residents which posed a potential safety risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
1
2
3
4
Cleared during inspection.
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: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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