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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 03/01/2021
Date Signed: 03/01/2021 03:56:39 PM

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 4FACILITY NUMBER:
079201036
ADMINISTRATOR:SIDDIQUI, SHAHIDFACILITY TYPE:
740
ADDRESS:5199 OLIVE DRIVETELEPHONE:
(415) 637-4977
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:8CENSUS: 5DATE:
03/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shahid SiddiquiTIME COMPLETED:
04:00 PM
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On 03/01/2021, Licensing Program Analysts (LPAs) Allison O'Hollaren and Lizette Francisco conducted a Tele-visit Pre-Licensing inspection via Microsoft Teams due to Shelter in Place order directed by the Governor. LPAs spoke with Administrator Shahid Siddiqui. The facility's fire clearance was approved for seven non-ambulatory and one bedridden.

During the tele-Inspection, LPAs toured facility with Administrator including but not limited to bedrooms, bathroom, common areas, kitchen, and outdoor area. COVID-19 signage is up in the facility. Resident's bedrooms are fully furnished with bed, dresser, night stand, and chair. Facility currently has five residents. Residents bathrooms were equipped with grab bars and non-skid mats. LPAs observed lighting in all rooms. Medications are stored and locked in a storage cabinet right next to the kitchen area. Smoke detectors are interconnected with sprinklers and fire department. Fire extinguisher was last serviced in September 2020. Carbon Monoxide detector was observed and in operation condition. Hot water temperature was measured 110 degrees F.

LPAs observed laundry detergent in resident bathroom underneath sink. LPAs also observed laundry room unlocked with laundry detergent accessible to residents. In addition, LPAs observed TV, TV stand and dresser blocking emergency exit door in resident's bedroom and unsecured cord in front of the door. When LPAs asked to open emergency exit door, door would not open from inside and then staff opened door from outside. Door was then able to lock and unlock inside resident's bedroom.

Prior to licensure, chemicals need to be inaccessible to residents and all pathways need to be free from obstruction.

Exit interview conducted and a copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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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