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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:58:02 PM


Document Has Been Signed on 09/19/2023 12:58 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
E BAY DELTA AC/SC, 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:
09/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shahid Siddiqui, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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On 09/19/2023 at 10:30 AM, Licensing Program Analyst (LPA) P. Watson conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Shahid Siddiqui and explained the purpose of the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, common areas, kitchen, and outdoor area. Hot water temperature was measured at 118.2, 116.2, and 120 degrees Fahrenheit in the resident bathrooms. Facility grocery shop every Wednesday. Resident's medications were kept locked in a cabinet near the dinning room. Smoke and carbon monoxide detectors were observed. First-aid kit was complete. Fire extinguisher was observed and last serviced on 10/20/2022. Indoor and outdoor passageways are free of obstruction.

The following deficiencies were observed during inspection:


-At 10:34 AM LPA observed bathroom cleaner in the cabinet in RM 8, deficiency cleared during visit, Administrator locked cleaning supplies in garage
-At 10:54 AM LPA observed eggs in the kitchen pantry, deficiency cleared during visit, LPA observed staff throw eggs away
-At 10:57 AM LPA observed unlocked medication in a kitchen drawer, deficiency cleared during visit, Administrator locked medications in medication cabinet
-At 11:00 AM LPA observed unlocked medication (tablets and insulin) in the kitchen refrigerator
-At 11:10 AM LPA observed a glucose testing machine and was informed by staff(S1) that they perform glucose testing for resident(R1).

The following deficiencies were observed (see LIC 809 D) 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 and a copy of this report provided along with Appeal rights
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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 3


Document Has Been Signed on 09/19/2023 12:58 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
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: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible...
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Deficiency cleared during visit. LPA observed Administrator lock medications in cabinet and garage.
Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures to CCL by 9/22/2023
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This requirement is not met as evidenced by:
Based on observation, medication (tablets and insulin) was accessible in the kitchen drawer and refrigerator which poses/posed an immediate Health, Safety risk to persons in care.
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Type A
09/20/2023
Section Cited
CCR87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Deficiency cleared during visit. Administrator locked cleaning solutions in garage.
Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures to CCL by 9/22/2023
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This requirement is not met as evidenced by:
Based on observation, bathroom cleaner (toilet bowl cleaner, windex, cleaner with bleach) was unlocked in residents bathroom which poses/posed an immediate Health, Safety risk to persons 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) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/19/2023 12:58 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
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: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
87555(b)(23)

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87555(b)(23) General Food Service Requirements
(b) The following food service requirements shall apply(23) All readily perishable foods ..capable of supporting rapid and progressive growth of micro-organisms which can cause food infections...shall be stored in covered containers at appropriate temperatures.
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Deficiency cleared during visit. LPA observed Staff throw eggs away in garbage bin
Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures to CCL by 9/22/2023
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This requirement is not met as evidenced by:
Based on observation, eggs were left in the kitchen pantry which poses/posed an immediate Health, Safety risk to persons in care.
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Type B
09/22/2023
Section Cited
CCR87628(a)

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87628(a) Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood .. and is able to administer his/her own medication ...
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Administrator will review regulation and submit a plan to address R1 diabetic care needs and submit a copy to CCL by POC date.
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This requirement is not met as evidenced by:
Based on observation and interview, LPA observed glucose testing machine and was informed that S1 performs glucose testing for R1 which poses/posed an immediate/potential Health, Safety risk to persons 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) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3