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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 04/16/2026
Date Signed: 04/16/2026 04:44:10 PM

Document Has Been Signed on 04/16/2026 04:44 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SAN LEANDRO SENIOR LIVINGFACILITY NUMBER:
015601394
ADMINISTRATOR/
DIRECTOR:		BERTUCCI, GLENDA TFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 90CENSUS: 62DATE:
04/16/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Glenda Bertucci, Executive Director TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On 4/16/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced case management visit regarding two self reported incidents that were reported to CCLD on 4/7/2026 and 4/10/2026. LPA met with Executive Director Glenda Bertucci and explained the purpose of the visit.

The first incident report stated that on 3/29/2026 around 9:00 am, Staff two (S2) was preparing resident (R1's) medication when S2 observed that the expiration date on the medication bottle indicated that it expired on 3/5/2026. The incident report indicated that R1 was given expired medication of Amlodipine 2.5 mg from 3/5/2026- 3/29/2026. On 3/29/2026, S2 noticed the expired medication and notified S3 to verify the expired medication and S3 re-confirmed that the medication was expired. R1's order is Amlodipine 2.5 mg: take 1 tablet by mouth 2x daily at 9:00 am. Physician and POA were notified of the incident. R1 was not resulted injury or medical problem due to this incident. In-service training was provided to staff on 3/30/2026.

The second incident report stated that on 4/3/2026 around 10:00 am, S1 was reviewing R1's Centrally Stored Medication and Destruction Record and observed that there was a discrepancy with medication dosage of R1's medication of Amlodipine 2.5 mg. S1 observed that R1 was given the Amlodipine 2.5mg but staff only gave R1 1 tablet per day due to the previous physicians order dated on 9/10/2025 that indicated to give R1 Amlodipine 2.5mg 1 tablet by mouth daily. When S1 was reviewing R1's documents S1 realized that the medication dosage was changed to Amlodipine 2.5mg: take 1 tab daily by mouth two times a day on the physicians order dated 12/29/2025 that was received from the Skilled Nursing facility when R1 returned back to the facility.

Continued on LIC809C.


NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAN LEANDRO SENIOR LIVING
FACILITY NUMBER: 015601394
VISIT DATE: 04/16/2026
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Continued from LIC809.

S1 stated that R1 was given 1 tablet of Amlodipine 2.5 mg daily as opposed to 1 tablet two times a day from 12/29/2025 to 4/3/2026. S1 stated that R1 was sent out to the hospital on 11/21/2026 and was later admitted to a Skilled Nursing Facility from 11/26/2025 - 12/29/2025. S1 stated that the Skilled Nursing Facility changed the dosage amount on 12/8/2026 while R1 was still attending the Skilled Nursing Facility. Physician and POA were notified of the incident. R1 did not result in injury or obtain ill side effects due to this incident. In-service training was provided to staff on 4/3/2026.

S1 acknowledged that both the under dosage and the expired medication was overlooked by staff. LPA interviewed S1 and S2. LPA attempted to interview S3. LPA reviewed and obtained R1's MAR (Medication Administration Record) from September 2025 - April 2026, updated Needs and Services Plan, Alert Charting report, Prescriber notification medication error report regarding Wrong Time and Wrong Dose, Physicians Order dated 9/10/2025, and Order Summary Report (Change of dosage) dated 12/29/2025. LPA also reviewed and obtained the Med Tech to Med Tech Communication Log, LIC500 (personnel Report), Resident Roster, and staff training.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalty.

Exit interview conducted with Glenda. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2026 04:44 PM - It Cannot Be Edited


Created By: Yasamin Brown On 04/16/2026 at 02:42 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: SAN LEANDRO SENIOR LIVING
FACILITY NUMBER: 015601394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2026
Section Cited
CCR
87465(d)

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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication... assist the resident with self-administration..
This requirement is not met as evidenced by:
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The Executive Director(ED) conducted staff training on Wrong Doses and Adverse Reactions on 4/3/2026. ED updated R1's Needs and Services Plan, and created a separate system for when the facility receives physician orders regarding resident medication changes.

DEFICIENCY CLEARED DURING VISIT.
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Based on Interview and record review, the licensee did not comply with the section cited above in administering the incorrect dosage of medication to R1 which poses an immediate health and safety risk to persons in care.
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Type A
04/17/2026
Section Cited
CCR87465(h)(1)(3)

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(h) The following requirements shall apply to medications which are centrally stored (1)Medications shall be centrally stored..(3) Each container shall carry all of the information.. (E) below plus expiration date and number of refills.
This requirement is not met as evidenced by:
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The Executive Director(ED) conducted staff training on Medication Errors and Adverse Reactions on 3/30/2026. ED updated R1's Needs and Services Plan, and utilized a system online called ADL Advantage for Med Tech's to utilize when reviewing medications.

DEFICIENCY CLEARED DURING VISIT.
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Based on Interview and record review, the licensee did not comply with the section cited above in administering expired medication to R1 which poses an immediate health and safety 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
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