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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200846
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:34:45 PM


Document Has Been Signed on 02/02/2023 03:34 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
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:
02/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:SHARMA, RAKHEE, Administrator TIME COMPLETED:
03:50 PM
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On 02/02/2023 at 2:40PM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced case management about Death report received on 01/30/2023, R1 passed away with unknown cause of death. LPA met with Administrator, Rakhee Sharma.

During the course of investigation, based on the interview with staff, R1 did not show any signs of medical emergency throughout the day. At around 2:00PM-4:00PM R1 took a nap. At around 3:30PM, S2 checked R1, it was observed that there was no sign of any medical emergency. R1’s family member visited her. Family member of R1 found her unresponsive at around 04:30PM. Staff called 9-1-1, paramedics arrived and pronounced R1 death at 4:43PM.

R1 passed away on 01/29/2023. Based on Police report it revealed that there was no foul play or any sign of abuse.

Based on interview with Administrator, R1 was under the care of hospice from 01/24/2022 and was discharged on 04/23/2022 with admission diagnosis of Cerebrovascular disease.

No deficiency cited during this visit.

Exit interview conducted. A copy of this report and was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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