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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:15:10 AM


Document Has Been Signed on 09/20/2022 11:15 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 4FACILITY NUMBER:
079201036
ADMINISTRATOR:SIDDIQUI, SHAHIDFACILITY TYPE:
740
ADDRESS:5199 OLIVE DRIVETELEPHONE:
(415) 637-4977
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:8CENSUS: DATE:
09/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Elmer "Eric" Ferrer, Care Staff TIME COMPLETED:
10:30 AM
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On 09/20/22 at 10:05 AM, Licensing Program Analyst LPA L. Holmes conducted an unannounced visit and explained the purpose to Care Staff, Elmer "Eric" Ferrer; this is to amend the report for complaint 15-AS-20201007102423 from Confidential to Public for the closed facility. Administrator Shahid Siddiqui was telephoned and approved Care Staff to sign the report.

Exit interview conducted and a copy of this report provided to Elmer "Eric" Ferrer.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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