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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:51:23 PM


Document Has Been Signed on 03/21/2024 05:51 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 4FACILITY NUMBER:
079201036
ADMINISTRATOR:SIDDIQUI, SHAHIDFACILITY TYPE:
740
ADDRESS:5199 OLIVE DRIVETELEPHONE:
(415) 637-4977
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:8CENSUS: 4DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver Elmer "Eric" FerrerTIME COMPLETED:
06:00 PM
NARRATIVE
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On 03/21/2024 at 12:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection of the facility. Upon arrival, LPA explained the purpose of the visit to Caregiver Milagros Ferrer. Administrator Shahid Siddiqui arrived at approximately 1:00 PM. The LPA interacted predominantly with Caregiver Elmer "Eric" Ferrer.

During the Inspection, the LPA inspected the inside of the facility. All indoor passageways were free of obstruction. A comfortable temperature is maintained at 68.8 degrees Fahrenheit. The LPA observed that the lighting in all rooms is adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Sharps were locked and inaccessible to residents. Fire extinguishers observed to be fully charged and last serviced 10/19/2023.

1 Type-B citation was issued during the visit.

Exit interview conducted with Caregiver Ferrer. A copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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Document Has Been Signed on 03/21/2024 05:51 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 4
FACILITY NUMBER: 079201036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee shall schedule appointments for the 4 residents to have an annual medical assessment wherein the physician will complete an LIC602 for the resident and that LIC602 will be added to their file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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