079201036-4-6-2023-15-AS-PWAN-CQMS2W-20230406133012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:30:30 PM

Document Has Been Signed on 04/06/2023 01:30 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	SPYGLASS SENIOR VILLA 4		FACILITY NUMBER:	079201036
ADMINISTRATOR:	SIDDIQUI, SHAHID		FACILITY TYPE:	740
ADDRESS:	5199 OLIVE DRIVE		TELEPHONE:	(415) 637-4977
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	8	CENSUS: 6	DATE:	04/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Shahid Siddiqui, Administrator		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/6/2023 at 9:40 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct 1 Year Annual Required inspection. LPA was greeted by Caregiver Elmer Ferrer. Administrator, Shahid Siddiqui, arrived at 10:12 AM. LPA explained the purpose of the visit. Administrator left the facility around 12:30 PM and allowed Elmer to sign the documents. The facility’s fire clearance was approved for 7 Non-Ambulatory and 1 Bedridden. LPA toured facility with Shahid including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 9 total bedrooms which 8 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. 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 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. LPA observed carbon monoxide and smoke detectors were in operating condition during visit, smoke detectors are connected to the sprinkler system. Fire extinguisher was last serviced on 10/20/2022. Emergency disaster drill was last conducted on 11/2023. Report continues on 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA 4	FACILITY NUMBER: 079201036
	VISIT DATE: 04/06/2023

NARRATIVE

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At 10:55 AM, LPA reviewed 6 residents records. At 11:55 AM LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 12:25 PM LPA reviewed a sample of 3 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/28/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
-At approximately 12:40 PM LPA observed that the first aid kit was incomplete.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/06/2023 01:30 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA 4	FACILITY NUMBER: 079201036
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)

Incidental Medical and Dental Care (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following..... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not maintain a comapleted first aid kit which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the kit did not contain a current manual, sterile first aid dressings, bandages, scissors nor tweezers.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Administrator will buy a completed first ait kit that contains all of the reqiuired items and submit photographic proof to CCL by POC date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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