079201036-2-15-2024-15-AS-HHUL-D4CQ3N-20240415114858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201036
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:19:05 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230915134017

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: 4	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Shahid Siddiqui, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not properly store residents' medications.

INVESTIGATION FINDINGS:

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On 09/15/2024 at 9:20 am, Licensing Program Analyst J Clancy-Czuleger arrived unannounced deliver findings for the above allegations. LPA met with Administrator Shahid Siddiqui, and explained the purpose of the visit.

During the course of the investigation, LPA interviewed staff and residents, and requested the following documents: LIC 500, resident roster, resident care plans, physician’s reports, recent incident and death reports, MARs for August and September, LIC 622, and shift notes for August and September.

It was alleged that, Staff did not properly store residents' medications. Based on observations during the initial 10-day visit, LPA observed unlocked medications in the refrigerator, kitchen drawer and observed the medicine cabinet was unlocked and accessible to residents. A deficiency was cited on 9/19/2023 (see LIC 809 dated 9/19/2023) and cleared.

Exit interview conducted and a copy of this report was provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230915134017

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: 4	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Shahid Siddiqui, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff failed to follow physicians orders resulting in questionable death.
Staff did not adequately supervise resident in care.
Staff did not address resident's change in condition while in care.
Facility is unsanitary and in disrepair.
Facility has pests.
Staff handled resident in care in a rough manner
Staff are sleeping in common areas
Facility failed to seek timely medical attention
Staff did not ensure that resident(s) were provided a sufficient amount of food while in care.

INVESTIGATION FINDINGS:

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On 02/15/2024 at 9:30 am, Licensing Program Analyst J Clancy-Czuleger arrived unannounced deliver findings for the above allegations. LPA met with Administrator and explained the purpose of the visit.

During the course of the investigation, LPA interviewed staff and residents, and requested the following documents: LIC 500, resident roster, resident care plans, physician’s reports, recent incident and death reports, MARs for August and September, LIC 622, and shift notes for August and September.

It was alleged that, Staff failed to follow physicians orders resulting in questionable death.
Based on death certificate obtained, R1 cause of death was listed as inanition. Underlying cause included severe protein calorie malnutrition heart disease, hypertension, and diabetes mellitus type 2. Resident was admitted to hospice prior to moving into the facility. R1 was previously hospitalized for achalasia of esophagus and pneumonia hospice care was revoked on 8/20/2023.

Continued on LIC9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20230915134017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/15/2024

NARRATIVE

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...Continued from LIC9099-A

Readmission to hospice care and facility occurred on 8/25/2023. Per hospice notes R1 had terminal diagnosis of severe protein calorie malnutrition and R1 ate small amounts of food throughout their time at the facility. The hospice agency (Anchor Health) provided the facility with a medication list and educated caregivers on signs and symptoms to look out for and how to respond.

It was alleged that, Staff did not adequately supervise resident in care.

Based on interviews with staff (S1 and S2), tasks are divided between them, and they alternate when caring for residents ADLs. There are currently 5 residents residing, who do not require 1:1 care and supervision. Based on interview with R2, S1 does most of the care, and overall care has been good.

It was alleged that, Staff did not address resident's change in condition while in care.

Based on record review, R1 was visited by Anchor Hospice providers, visit notes did not express any changes of their condition. R1 was verbal with Hospice providers about their condition, if they expressed any pain or discomfort facility staff provided them with their PRN medications.

It was alleged that, Facility is unsanitary and in disrepair, and Facility has pests.

Based on observations during initial visit conducted on 9/19/2023, LPA observed including but not limited to the floors, bathrooms, bedrooms and common areas to be clean, in good repair and without pests.

It was alleged that, Staff handled resident in care in a rough manner.

Based on record review, R1 did not have evidence of bruising or signs that they have been handled in a rough manner. Based on interviews with residents (R2), staff have not handled them roughly.

It was alleged that, Staff are sleeping in common areas.

Based on observations and interviews with staff, staff are live-in and occupy designated staff rooms. Based on interviews with residents, (R2) they have not observed staff sleeping in common areas.

Continued on LIC9099C....

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20230915134017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/15/2024

NARRATIVE

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...Continued from LIC9099C

It was alleged that, Facility failed to seek timely medical attention.

Based on record review, Anchor hospice was present at the facility on 09/11/2023 from 12:20 PM until R1 was declared deceased at 12:50 PM. Based on interviews with staff (S1), when R1 passed away, S1 informed the Administrator and the Administrator contacted R1 family members.

It was alleged that, Staff did not ensure that resident(s) were provided a sufficient amount of food while in care.

Based on observations, LPA observed a significant supply of perishable and non-perishable food located in the kitchen and garage. Administrator stated that they grocery shop every Wednesday.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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