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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200607
Report Date: 07/29/2026
Date Signed: 07/29/2026 04:02:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251222151145
FACILITY NAME:SPYGLASS SENIOR VILLA IIIFACILITY NUMBER:
079200607
ADMINISTRATOR:SIDDIGUI, SHAHIDFACILITY TYPE:
740
ADDRESS:2870 FALCON CTTELEPHONE:
(415) 637-4977
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:8CENSUS: 7DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Gilbert Villola, CaregiverTIME COMPLETED:
04:21 PM
ALLEGATION(S):
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Facility restraining residents in care
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20251222151145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 079200607
VISIT DATE: 07/29/2026
NARRATIVE
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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.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251222151145

FACILITY NAME:SPYGLASS SENIOR VILLA IIIFACILITY NUMBER:
079200607
ADMINISTRATOR:SIDDIGUI, SHAHIDFACILITY TYPE:
740
ADDRESS:2870 FALCON CTTELEPHONE:
(415) 637-4977
CITY:BRENTWOODSTATE:CAZIP CODE:
94513
CAPACITY:8CENSUS: 7DATE:
07/29/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Gilbert Villola, Caregiver TIME COMPLETED:
04:21 PM
ALLEGATION(S):
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Facility not providing adequate incidental medical and dental care/assistance
INVESTIGATION FINDINGS:
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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 Siddiqui, 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...






Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20251222151145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 079200607
VISIT DATE: 07/29/2026
NARRATIVE
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20251222151145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 079200607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2026
Section Cited
CCR
87608(a)(3)
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(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:
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BY POC date. Licensee agreed to read regulation 87608 and send a self-certifying email to CCL
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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 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5