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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 07/05/2022
Date Signed: 07/05/2022 04:58:17 PM


Document Has Been Signed on 07/05/2022 04:58 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 4FACILITY NUMBER:
079201036
ADMINISTRATOR:SIDDIQUI, SHAHIDFACILITY TYPE:
740
ADDRESS:5199 OLIVE DRIVETELEPHONE:
(415) 637-4977
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:8CENSUS: 6DATE:
07/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:26 PM
MET WITH:Administrator, Shahid Siddiqi TIME COMPLETED:
05:10 PM
NARRATIVE
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On 07/05/22 at 4:25 PM, Licensing Program Analyst LPA L. Holmes conducted an unannounced subsequent visit and met with Administrator, Shahid Siddiqi to deliver the findings of complaint 15-AS-20201007102423 for a closed facility.

On 11/08/21 LPAs L Holmes and L Francisco requested for Administrator to submit the following documents to CCL by 11/15/21: Resident Roster for 2020 and 2021, Physician's Report, Needs and Services Plan, Centrally Stored Medication and MAR for August - September 2020, Identification and Emergency Information. LPA received incomplete documents on 11/15/2021.


On 04/27/22 LPA requested All pages for the Physician’s Report for R1 dated May of 2020, Admission Agreement; R1’s last day at the facility was 09/28/2020. On 04/30/22 ADM said he'd get back to me and on 05/19/2022. ADM stated he located R1’s binder. The binder had incomplete and missing documents.

Deficiencies is cited from California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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Document Has Been Signed on 07/05/2022 04:58 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SPYGLASS SENIOR VILLA 4
FACILITY NUMBER: 079201036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited

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87506 Resident Records
(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
-This requirement is not met as evidenced by:
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-Based on interviews and record reviews, the licensee did not comply with the section above by not retaining all of R1's records for at least 3 years which posed potential health and personal rights risks to person in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2