079200844-5-7-2024-15-AS-TSGN-D52TNX-20240507145327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200844
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:53:45 PM

Document Has Been Signed on 05/07/2024 02:53 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 I		FACILITY NUMBER:	079200844
ADMINISTRATOR:	SHARMA, RAKHEE		FACILITY TYPE:	740
ADDRESS:	39 CALLA CT		TELEPHONE:	(925) 684-7331
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 5	DATE:	05/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Rhonette Santos Caregiver		TIME COMPLETED:	03:00 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 05/07/2024 at 9:47AM, Licensing Program Analysts (LPA) T.Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Rhonette Santos, spoke with Administrator Rakhee Sharma via telephone, and explained the purpose of the visit. The Administrator arrived at 10:49AM and currently holds a certificate (#6011933740) that expires on 08/07/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA explained to Administrator that it is required to be available at the facility during the hours indicated on the LIC500. Administrator stated the schedule is wrong and will update schedule with actual hours available during normal business hours and send to CCLD. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. 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 120.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and no 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 10/10/2023. Emergency Disaster Plan was last posted on 01/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 03/25/2024. Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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 4

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 I	FACILITY NUMBER: 079200844
	VISIT DATE: 05/07/2024

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
26
27
28
29
30
31
32

Continued from LIC809.

LPA reviewed five (5) resident records and three (3) staff records, and they were current and complete. LPA also reviewed a sample of medication.

LPA requested the following documents to be submitted to CCLD by 05/14/2024:

· LIC 200 and Updated Facility Sketch
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report (Updated with Administrator available hours during normal business hours)
· LIC 610E Emergency Disaster Plan

LPA observed the following deficiency:

· At 10:19AM LPA observed food stored and locked in the laundry room

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 and appeal rights provided.

Continue on LIC809D

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/07/2024 02:53 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 I	FACILITY NUMBER: 079200844
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(3)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. 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 having nonperishable foods stored and locked in laundry room which poses a personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Administrator immediately had staff remove nonperishable foods from laundry room and placed them in the kitchen cabinet. Deficiency cleared during the 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4