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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200846
Report Date: 06/22/2022
Date Signed: 06/22/2022 11:50:29 AM


Document Has Been Signed on 06/22/2022 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIFACILITY NUMBER:
079200846
ADMINISTRATOR:SHARMA, RAKHEEFACILITY TYPE:
740
ADDRESS:75 BOTTLE BRUSH CTTELEPHONE:
(415) 630-0266
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 5DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Rakhee Sharma, Administrator TIME COMPLETED:
12:15 PM
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On June 22, 2022 at 9:55 AM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with Eufrecina Metra staff and Rhonette Santos house manager informed the purpose of visit. LPA called Administrator and informed her the purpose of the visit. Administrator arrived at the facility around 11:10AM. Facility has census of 5. Hospice waiver approved for 4 residents. Currently facility has 1 hospice resident in care.

LPA started the inspection with Eufrecina Santos. LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen, garage and backyard and side yard. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every 30 days.

Water temperature was tested in the common bathroom and measured at 109.7 degrees Fahrenheit. Fire extinguisher checked; tag showed inspected on October 2021.

No deficiency cited during the visit.

Exit interview conducted with Rakhee Sharma. Appeal Rights and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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