Spyglass Senior Villa III

Allegation investigated: Facility restraining residents in care

On 07/29/2026 at 2:30PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Gilbert Villola, Caregiver and explained the reason for the visit. Gilbert contacted Shahid Siddigui, Administrator to advise him of the visit. Administrator arrived at approximately 3:12PM. During the course of investigation LPA toured facility, interviewed W2, S1, S2, S3, LPA was not able to interview resident (s) due to their diagnosis. LPA reviewed and obtained the following documents: staff schedule, staff contact information, residents’ roster, resident’s (R1's) admission agreement, physician’s report, daughter's contact information and appraisal needs and service plan. Continue on LIC9099C... Substantiated Continued from LIC9099 Allegation: Facility restraining residents in care Interview with W2, stated believes facility is restraining resident (R1) to prevent (R1) from wandering. Interview with W2 also stated facility advised W2 it’s for R1’s safety and will prevent falls. Interviews S1, S2 and S3 stated R1 were admitted to the facility with a wheelchair that had a belt attached to it. Interview with S1 stated R1’s daughter advised S1 the belt was in place to prevent R1 from falling. S1 stated that prior to R1 moving into facility R1 was hospitalized and was a fall risk. Interview with S2 and S3 stated when R1 was admitted to the facility the wheelchair had the belt attached to it and staff were told by R1’s daughter it’s there to prevent R1 from falling. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report and appeal rights were given to Shahid Siddiqui. Continued from LIC9099 Allegation: Facility not providing adequate incidental medical and dental care/assistance Interview with W2 stated W2 would take R1 to all doctor appointments, W1 also stated R1 was receiving Home Health (HH) services while at the facility. Interviews with S1, S2 and S3 stated family members are responsible for taking all residents to their medical and dental appointments, the facility does not provide transportation. Interview with S1 stated, facility will assist any family members who need assistance with arranging transportation for residents to get to their medical/dental appointments, however, no one has asked for assistance. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 15-AS-20251222151145

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Aug 8, 2026

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal.... 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........ This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in not having doctor orders for wheelchair belt which posed a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: BY POC date. Licensee agreed to read regulation 87608 and send a self-certifying email to CCL

Type of visit: POC

On 2/13/2026 at 2:45 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Plan of Correction (POC) Inspection. Upon entry, the LPA stated the purpose of the visit to Caregiver Jake Lapuz. At approximately 3:30 PM Licensee / Administrator Shahid Siddiqui arrived. The LPA reviewed facility documents, toured the facility, interviewed the Administrator, and interviewed Staff S1 and S2. All Plans of Correction were completed and clearance letters issued to Licensee. No citations issued during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 13, 2026

Type of visit: Case Management - Annual Continuation

On 1/28/2026 at 10:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Case Management Annual Continuation Inspection. Upon entry, the LPA stated the purpose of the visit to Caregiver Jake Lapuz, shortly thereafter the LPA spoke with Administrator Shahid Siddiqui by phone. The LPA reviewed facility documents, 5 resident records, and 5 staff records. 14 Type B citations were issued during the inspection. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Failure to submit Proof of Corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. The Required Annual Inspection is complete. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Required - 1 Year

On 1/26/2026 at 2:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Required Annual Inspection. Upon entry, the LPA stated the purpose of the visit to Administrator Shahid Siddiqui. The LPA toured the facility, including but not limited to, residents’ rooms, bathrooms, kitchen, common areas and the backyard. The LPA observed adequate lighting for the comfort and safety of residents in all rooms. Inside and outside areas are free of obstruction and no bodies of water. The temperature in the dining room was measured at 75.3 degrees Fahrenheit. The residents’ bathrooms are equipped with grab bars and slip-resistant mats. There is more than the minimum of a one week supply of nonperishable foods and 2 days of perishable foods. The LPA observed the required postings in the facility. Smoke detectors and carbon monoxide detectors were tested and found to be in operating condition. The fire extinguisher was fully charged and serviced on 11/14/2025. Continued on LIC 809-C . . . . . . Continued from LIC 809 The following citations were issued during the inspection: Type A: Maximum hot water temperature was measured at 125.4 degrees Fahrenheit Type A: Centrally stored medication cabinet was unlocked. Type A: Cabinet with cleaning products under kitchen sink not locked. Type B: 4 of 30 cans checked beyond best buy date Type B: Cheese Whiz that had been opened was left in cabinet and not refrigerated. The LPA reviewed 5 resident records and 5 staff records. 3 Type A and 2 Type B citations were issued during the inspection. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Failure to submit Proof of Corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. The Required Annual Inspection is not complete. The LPA will return to complete it unannounced at a future date and time. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

Type of visit: Case Management - Other

On 5/8/2025 at 12:00pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Jake Lapuz, Caregiver, and explained the reason for the visit. Administrator, Shahid Siddigui, arrived at 1:20pm. While LPA L. Hall was conducting a collateral visit at the facility on 5/8/2025. LPA observed during record review S1 was not associated to the facility. LPA observed facility was cited for same staff on 1/24/2025, for not being associated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report and appeal rights providedthe state’s words, verbatim · CDSS document, May 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(3) · Plan of correction due date: May 9, 2025

(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.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Administrator agreed to send LIC9182 and S1 identification to CCLD to be associated.

Type of visit: Required - 1 Year

On 01/24/2025 at 10:25AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Gilbert, Villota spoke with Administrator, Shahid Siddiqui via telephone, and explained the purpose of the visit. The Administrator currently holds a certificate (#6043867740) that expires on 03/15/2025. The facility’s fire clearance was approved for eight (8) non-ambulatory residents. Administrator had to leave during visit and gave authorization to Gilbert Villota, Caregiver to sign reports. LPA toured the facility with Caregiver, Gilbert Villota including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and four (4) bathrooms. one (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/14/2024. Emergency Disaster Plan was last posted on 02/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 09/14/2019. Continue on LIC809C Continued from LIC809. Four (4) staff records were reviewed, three (3) staff members were missing annual training, S4 wasn't associated and was missing Health Screening . LPA reviewed all five (5) resident records, and they were incomplete. LPA requested the following documents to be submitted to CCLD by 01/31/2025. · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (last page) · Liability Insurance LPA observed the following deficiencies: At 11:20AM, LPA observed all five residents has hospital beds with bed rails At 12:15PM, LPA observed during file review all five residents files were incomplete At 12:30PM, LPA observed during file review three (3) out of four (4) staff did not have annual training and S4 was missing Health Screening and was not associated to the facility Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted a copy of this report, appeal rights and LIC412FC providedthe state’s words, verbatim · CDSS document, Jan 24, 2025

Allegation investigated: Staff did not keep resident's door free from obstruction.

On 3/26/2024 10:10am, Licensing Program Analysts (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the above allegations. LPAs met with Alice Fontela, Caregiver and explained the reason for the visit. Administrator, Shahid Siddigui, arrived at 10:48am. During the visit LPAs toured facility, obtained and reviewed staff schedule and resident roster. During tour LPAs did not observe any doors leading to bedrooms or exterior doors blocked. Continued on LIC9099C. Unsubstantiated Continued from LIC9099. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 15-AS-20240320125332

Type of visit: Case Management - Other

On 3/26/2024 at 10:35am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct a Case Management visit. LPA met with Alice Fontela, Caregiver, and explained the reason for the visit. Administrator, Shahid Siddigui arrived at 10:38am. While LPA L. Hall was conducting a complaint investigation (15-AS-20240320125332) on 3/26/2024, upon arrival LPAs observed a cup containing two (2) yellow pills sitting on kitchen table unattended. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874659(h)(2) · Plan of correction due date: Mar 27, 2024

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.the state’s words, verbatim · CDSS document, Mar 26, 2024

Plan of correction: Caregiver immediately locked medication away in medication cabinet. Deficiency cleared during visit.

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Jan 30, 2024