079200607-1-30-2024-15-AS-AGOZ-CZZ39L-20240130170318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200607
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:03:26 PM

Document Has Been Signed on 01/30/2024 05:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	SPYGLASS SENIOR VILLA III		FACILITY NUMBER:	079200607
ADMINISTRATOR:	SIDDIGUI, SHAHID		FACILITY TYPE:	740
ADDRESS:	2870 FALCON CT		TELEPHONE:	(415) 637-4977
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	8	CENSUS: 6	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:	Administrator, SHAHID SIDDIQUI		TIME COMPLETED:	05:15 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 01/30/2024 at 1:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with caregiver Alicia Fontela and explained the purpose of the visit. Administrator, SHAHID SIDDIQUI arrived at approximately 3:00pm and explained the purpose of the visit. The facility’s fire clearance was approved for 8 Non-Ambulatory. Hospice waiver approved for 4. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 125.2 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of nonperishables and 2-day perishables food supply. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/14/2023. First aid kit was observed to be complete. At 1:45pm, 5 of 6 clients records were reviewed. At 2:30pm, 4 staff records were reviewed and 4 of 4 have current first aid training and associated to the facility. Report Continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA III	FACILITY NUMBER: 079200607
	VISIT DATE: 01/30/2024

NARRATIVE

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The following Deficiencies were observed during Visit

During File review LPA observed that all resident files are incomplete and missing Emergency consent forms, Personal rights, Emergency ID's, and other forms
At 4:00pm During Facility tour LPA observed Hot water temperature in residents shared bathroom measuring at 125.2 degrees F.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 01/13/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610E Emergency Disaster Plan
Updated Facility Sketch and Fire Clearence

The following deficiencies were 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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/30/2024 05:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA III	FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the water temprature measuring at 125.2 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to adjust water temrature in accordance with regulation and self submit to CCLD.

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/30/2024 05:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA III	FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident records being incomplete which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to update and complete all resident records and self certify to CCLD.

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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