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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200846
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:37:00 PM


Document Has Been Signed on 05/16/2024 01:37 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 IIFACILITY NUMBER:
079200846
ADMINISTRATOR:SHARMA, RAKHEEFACILITY TYPE:
740
ADDRESS:75 BOTTLE BRUSH CTTELEPHONE:
(925) 684-7331
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Gloria Rueda CaregiverTIME COMPLETED:
01:45 PM
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On 05/16/2024 at 10:50AM, Licensing Program Analysts (LPA) T.Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Gloria Rueda, spoke with Administrator Rakhee Sharma via telephone, and explained the purpose of the visit. The Administrator arrived at 11:08AM and currently holds a certificate (#6049443740) that expires on 08/21/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

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 77 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 110.8 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 05/08/2024. First aid kit was observed to be complete. Fire drill was last conducted on 03/25/2024.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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 2


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 II
FACILITY NUMBER: 079200846
VISIT DATE: 05/16/2024
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Continued from LIC809

LPA reviewed five (5) resident records and three four (4) staff records, and they were current and complete. LPA also reviewed a sample of medications.

LPA requested the following documents to be submitted to CCLD by 05/23/2024:

· LIC 200 and Updated Facility Sketch
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report (Updated)
· LIC 610E Emergency Disaster Plan
· Liability Insurance
· Current Administrator's Certificate

LPA observed no deficiencies during visit

Exit interview conducted. A copy of this report provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2