SPYGLASS SENIOR VILLA III

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. No Plan of Operation at facility, so no description of the ways in which the Licensee will address resident behavioral expression as defined in Section 87101 and no infection control plan LIC 9282 at facility, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date the Licensee will attest to LPA Sampair that the Plan of Operation is at the facility and that he has shown staff where it is located and that it is now part of new staff training to show them where it is located.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above with a staff shortage for more than two weeks, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date the Licensee will attest to LPA Sampair that he has reviewed Section 87413 of Title 22.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above. Shahid Siddiqui is not conducting administrative duties at the facility a minimum of 20 hours per week during normal working hours, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/25/2026 Plan of Correction On or before the due date the Licensee shall have an administrator conducting administrative duties at the facility a minimum of 20 hours per week during normal working hours.

Official classification

Type B

Official code

87412(e)

Regulation authority

CCR

What the official deficiency says

(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. The posted LIC 500 has hours for Administrator who is not at the facility during those times and prospective caregiver who has not yet been cleared to care for residents, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date the Licensee will create an accurate LIC 500 and send it to LPA Sampair via email.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. 0 of 2 staff completed 20 hours of training. Medication training is a separate requirement and is not included in the 20 hours, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date the Licensee will send documentation to LPA Sampair that both of the staff members have completed 20 hours of training.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. 1 staff assisting residents with medication never had medication training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date the Licensee will have the staff member complete the medication training and send via email proof to LPA Sampair.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 5 out of 5 residents, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, Licensee shall carefully review Section 87219 of Title 22 and attest to LPA Sampair by email that they have reviewed it.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. A majority of the required resident documents are missing: LIC 621 2 of 5 missing, LIC 601 5 of 5 missing, LIC 627C 5 of 5 missing, and LIC 613C-2 2 of 5 missing, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, Licensee will get signed, dated, and completed documents LIC 621, LIC 601, LIC 627C, and LIC 613C-2. The Licensee will attest to LPA Sampair by email that those have been retained or promises from families have been made to send them by the end of February.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents by using the wrong form. He needs to use LIC 603A RESIDENT APPRAISAL and LIC 9172 FUNCTIONAL CAPABILITY ASSESSMENT instead to conduct Pre-Admission Appraisals, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, Licensee shall carefully review Section 87456 and 87457 of Title 22 and attest to LPA Sampair by email that he has reviewed it.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. 2 of 3 residents living at facility more than 12 months did not have their annual reappraisal, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, the Licensee shall complete the annual Appraisal, Needs, and Services form for all of the residents in need, and attest to LPA Sampair by email that they have reviewed it.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. 2 of 3 residents living at facility more than 12 months did not have their annual routine visits, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, the Licensee shall schedule all of the residents in need for their annual routine visit, and attest to LPA Sampair by email that the appointments have been scheduled as soon as possible.

Official classification

Type B

Official code

87507(l)

Regulation authority

CCR

What the official deficiency says

(l) The licensee shall attach a copy of applicable resident's rights specified by law or regulation to all admission agreements, and shall include information on the reporting of suspected or known elder and dependent abuse, as set forth in Health and Safety Code Section 1569.889. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above.2 of the 5 resident files had no Personal Rights (LIC 613C) in them, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, the Licensee shall get completed, signed and dated LIC 613Cs for every resident where they are missing and attest to LPA Sampair by email that they have been collected for those residents.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2025, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction On or before the due date, the Licensee shall complete the quarterly drill with all staff members and schedule the future drills for 2026 and beyond and provide proof to LPA Sampair by email.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in no physician's orders for 2 of the 5 residents which posed a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Cleared during inspection.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 Based on observation, the licensee did not comply with the section cited above. The maximum hot water temperature was measured at 125.4 degrees Fahrenheit, which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction On or before due date, the Licensee shall send message to LPA Sampair that the max temperature is between 105 and 120 degrees Fahrenheit.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Cabinet with cleaning products under kitchen sink not locked, which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction Cleared during visit.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Centrally stored medication cabinet was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction Cleared during visit.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. 4 of 30 cans checked beyond best buy date, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Cleared during visit.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Cheese Whiz that had been opened was left in cabinet and not refrigerated, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Cleared during visit.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review... shall prior to working.. in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S1 associated to the facility, which poses an immediate health and safety risk to person in care.

Official plan of correction

Administrator agreed to send LIC9182 and S1 identification to CCLD to be associated.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or.. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, licensee did not comply with the section cited above by not associating S1 to the facility which poses a potential health and safety risk to the persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Administrator agreed to associate S4 and send a self- certifying email to CCLD by POC date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608(a)(3) Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having five (5) out five (5) residents in hospital beds with bed rails without orders which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Administrator agreed to obtain orders for hospital beds with bed rails and send CCLD an email by POC date.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not having three (3) staff members complete annual training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Administrator agreed to have staff complete annual training and send a self certifying email to CCLD by POC date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not having S4 health screening which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Administrator agreed to have S4 obtain a health screening and send CCLD an email by POC date.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

87506 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 Based on record review, the licensee did not comply with the section cited above in having 5 out of 5 resident records being incomplete which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Administrator agrees to update and complete all resident records by POC date

Official classification

Type A

Official code

874659(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 (h) The following requirements shall apply to medications which are centrally stored: (2) ...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidence by: Based on LPAs observation the Licensee did not comply with the section cited above in having medication inaccessible to residents, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Caregiver immediately locked medication away in medication cabinet. Deficiency cleared during visit.

Deadline recorded: Mar 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/31/2024 Plan of Correction By POC date administrator agrees to adjust water temrature in accordance with regulation and self submit to CCLD.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 02/13/2024 Plan of Correction By POC date administrator agrees to update and complete all resident records and self certify to CCLD.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

(a)Each licensee shall furnish to the licensing agency such reports...including, but not limited to, the following: (2) Occurrences, such as...which threaten the welfare, safety or health of residents.... This requirement is not met as evidenced by… Based on interview the licensee did not comply with the section cited above. Facility failed to report incident to CCL when incident occurred which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review regulation and submit a self-certification to be in compliance in future events to CCL by the POC due date.

Deadline recorded: May 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons...(2) Bedridden persons Based on observation and interviews, Licensee failed to obtain fire clearance for two (2) (R2 & R3) bedridden residents. LPA observed and records review revealed that R2 & R3 is bedridden. However, facility does not have bedridden clearance which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator/Licensee agreed to notify the fire department within 24 hours that R2 & R3 are bedridden, shall submit to licensing an LIC200, updated facility sketch, along with a request for a fire inspection to retain a bedridden resident at facility by POC date (02/24/2023) A civil penalty of $500.00, is being assessed today.

Deadline recorded: Feb 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80075(k)(1)

Regulation authority

CCR

What the official deficiency says

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to persons in care.

Official plan of correction

S3 locked the medication. Administrator agreed to conduct in-service training with all the staff. Proof of training with staff names, signature and copy of training topic needs to be submitted to CCL by 02/27/2023. Corrected during the visit.

Deadline recorded: Feb 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having unlocked disinfectants and cleaning products in the which poses an immediate health and safety risk to persons in care.

Official plan of correction

S3 locked the medication. Administrator agreed to conduct in-service training with all the staff. Proof of training with staff names, signature and copy of training topic needs to be submitted to CCL by 02/27/2023.

Deadline recorded: Feb 24, 2023. A deadline is not proof that correction was completed.