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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201036
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:08:40 PM

Document Has Been Signed on 01/15/2025 02:08 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SPYGLASS SENIOR VILLA 4FACILITY NUMBER:
079201036
ADMINISTRATOR/
DIRECTOR:		SIDDIQUI, SHAHIDFACILITY TYPE:
740
ADDRESS:5199 OLIVE DRIVETELEPHONE:
(415) 637-4977
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 8CENSUS: 3DATE:
01/15/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Siddiqui Shahid, Administrator.TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On 01/15/2025 Licensing Program Analyst (LPA) K. Nguyen met with Administrator, Shahid Siddiqui and conducted a case management during a pre-licensing visit.

The following deficiencies were observed during inspection:



LPA observed cleaning supplies and other chemical in all the bathroom cabinets.
LPA observed unlocked medication in a kitchen drawer, and inside resident dresser.

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 is conducted. A copy of appeal right and report is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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 01/15/2025 02:08 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 01/15/2025 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SPYGLASS SENIOR VILLA 4
FACILITY NUMBER: 079201036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2025
Section Cited
CCR
87309

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:

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Administrator (ADM) agree to removed and locked up chemical and medication and review the regulation and submit a self-certification that ADM understand the regulation and submit photo proof to CCLD by 1/17/25. ADM will conduct an in service to all care staff and submit proof of training to CCLD by 1/22/25.
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Based on observation , the licensee did not comply with the section cited above by having cleaning supplies and other chemical in all the bathroom cabinets unlocked, and unlocked medication in a kitchen drawer, and inside resident dresser, which poses an immediate health, safety or personal rights 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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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