Spyglass Senior Villa 4

Type of visit: Case Management - Deficiencies

On 03/23/2026 at 12:00PM, Licensing Program Analyst (LPA) Andrew Christy spotted and cited the following deficiency during a Pre-Licensing of the facility as Harmony House Care Home: At 12:15PM, when opening the utensil drawer in the kitchen, two roach nymphs were spotted. Deficiencies are 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, along with Appeal Rights, was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 3, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, two roach nymphs were found in the kitchen utensil drawer which poses a potential health risk.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: On or before plan of correction due date, pest control will be called to perform services and a receipt of the services performed will be emailed to CCLD.

Type of visit: Required - 1 Year

On 03/09/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Administrator, Dr. Bamikole Ogundele, and explained the purpose of the visit. The facility is currently at max capacity with eight (8) residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 70.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 118.3 degrees Fahrenheit. LPA observed lighting in all rooms are 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 non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/30/2025. At 10:30AM, LPA reviewed five (5) resident files and two (2) staff files, all found to be complete. The emergency disaster plan was last reviewed 02/02/2026. Quarterly emergency drills were last conducted 02/23/2026. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Mar 9, 2026

Type of visit: Case Management - Other

On 11/25/2025 at 9:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct a Case Management. LPA met with caregiver Manancy Ferrer and explained the purpose of the visit. Administrator Dr. Bam Ogundele arrived around 10:45AM. The facility currently houses four (4) residents with a max capacity of eight (8) residents. During the visit, LPA collected the following documents: R1's LIC602, R1's Appraisal Needs and Services Plan, and R1's medication list The purpose of the visit is to discuss a received SOC341 regarding a resident (R1) complaining of financial abuse from their one of their children (W1). Per caregiver staff and administrator, R1 and W1 have not had any arguments happen during visits. Administrator understands that financial abuse is a serious matter, and has not suspected any financial abuse as payments are received on time. Administrator stated that, if financial abuse is suspected, they know to report to Adult Protective Services (APS) and the state ombudsman. Administrator also understands that, if the patient wants to refuse visits from guests such as W1, they have the right to do so. No deficiencies cited during visit. Exit interview conducted and a copy of this report was made available to the administrator.the state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Required - 1 Year

On 4/02/2025 at 9:50AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Ma Nancy Ferrer and explained the purpose of the visit. The Administrator currently holds a certificate (#6043867740) that expired on 03/15/2025 and is waiting for renewed certificate. The facility’s fire clearance was approved for seven (7) non-ambulatory and one (1) bedridden residents. Administrator arrived at 12:30PM. LPA toured the facility with Caregiver then Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of eight (8) total bedrooms. There are five (5) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no 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. Residents’ bathrooms are equipped with grab bars. Hot water temperature in the shared clients’ bathroom was measured at 105 degrees Fahrenheit. 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 10/16/2024. Emergency Disaster Plan was last posted on 03/22/2024. First aid kit was observed to be complete. Continued on LIC809C Continued from LIC809 LPA reviewed two (2) staff records, and all staff have criminal record clearance and holds a current first aid/CPR certificate. two (2) Clients records were reviewed all complete. DEFICIENCIES OBSERVED DURING VISIT: At 11:20AM LPA observed medication door was unlocked. At 11:23AM LPA observed a roach in a kitchen cabinet. At 11:26AM LPA observed a laundry room unlocked with the key hanging in the lock. LPA requested the following documents by 04/18/2025. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted, a copy of this report and appeals rights provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Jan 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309 · Plan of correction due date: Jan 17, 2025

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: 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.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Mar 21, 2024

Allegation investigated: Staff did not properly store residents' medications.

On 09/15/2024 at 9:20 am, Licensing Program Analyst J Clancy-Czuleger arrived unannounced deliver findings for the above allegations. LPA met with Administrator Shahid Siddiqui, and explained the purpose of the visit. During the course of the investigation, LPA interviewed staff and residents, and requested the following documents: LIC 500, resident roster, resident care plans, physician’s reports, recent incident and death reports, MARs for August and September, LIC 622, and shift notes for August and September. It was alleged that, Staff did not properly store residents' medications. Based on observations during the initial 10-day visit, LPA observed unlocked medications in the refrigerator, kitchen drawer and observed the medicine cabinet was unlocked and accessible to residents. A deficiency was cited on 9/19/2023 (see LIC 809 dated 9/19/2023) and cleared. Exit interview conducted and a copy of this report was provided. Substantiated ...Continued from LIC9099-A Readmission to hospice care and facility occurred on 8/25/2023. Per hospice notes R1 had terminal diagnosis of severe protein calorie malnutrition and R1 ate small amounts of food throughout their time at the facility. The hospice agency (Anchor Health) provided the facility with a medication list and educated caregivers on signs and symptoms to look out for and how to respond. It was alleged that, Staff did not adequately supervise resident in care. Based on interviews with staff (S1 and S2), tasks are divided between them, and they alternate when caring for residents ADLs. There are currently 5 residents residing, who do not require 1:1 care and supervision. Based on interview with R2, S1 does most of the care, and overall care has been good. It was alleged that, Staff did not address resident's change in condition while in care. Based on record review, R1 was visited by Anchor Hospice providers, visit notes did not express any changes of their condition. R1 was verbal with Hospice providers about their condition, if they expressed any pain or discomfort facility staff provided them with their PRN medications. It was alleged that, Facility is unsanitary and in disrepair, and Facility has pests. Based on observations during initial visit conducted on 9/19/2023, LPA observed including but not limited to the floors, bathrooms, bedrooms and common areas to be clean, in good repair and without pests. It was alleged that, Staff handled resident in care in a rough manner. Based on record review, R1 did not have evidence of bruising or signs that they have been handled in a rough manner. Based on interviews with residents (R2), staff have not handled them roughly. It was alleged that, Staff are sleeping in common areas. Based on observations and interviews with staff, staff are live-in and occupy designated staff rooms. Based on interviews with residents, (R2) they have not observed staff sleeping in common areas. Continued on LIC9099C.... ...Continued from LIC9099C It was alleged that, Facility failed to seek timely medical attention. Based on record review, Anchor hospice was present at the facility on 09/11/2023 from 12:20 PM until R1 was declared deceased at 12:50 PM. Based on interviews with staff (S1), when R1 passed away, S1 informed the Administrator and the Administrator contacted R1 family members. It was alleged that, Staff did not ensure that resident(s) were provided a sufficient amount of food while in care. Based on observations, LPA observed a significant supply of perishable and non-perishable food located in the kitchen and garage. Administrator stated that they grocery shop every Wednesday. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 15-AS-20230915134017