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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600073
Report Date: 07/27/2020
Date Signed: 07/27/2020 02:58:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CASA SANDOVALFACILITY NUMBER:
015600073
ADMINISTRATOR:ROSANA FRIASFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: 62DATE:
07/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted a case management via video conference with Associate Executive Director Rosana Frias. LPA informed Ms. Frias that the purpose of the case management is regarding the incident reported by Ms. Frias to LPA on July 13, 2020 followed by a written report submitted on July 14, 2020 along with the requested copy of Physician's Report.

Report indicated that on July 12, 2020, first responders (fire, EMT and police officers) came to the facility for resident (R1). At the time of the incident, staff (S1) was not able to obtain information as she stayed outside R1's apartment per request by R1. R1 was brought to the hospital. Report further indicated that Wellness Director will conduct reassessment to determine if R1's care needs can still be provided by the facility.

LPA learned that R1 is now at the facility. R1 was admitted back on July 23rd.

On this day, July 27, 2020, LPA conducted interviews. LPA requested Ms. Frias to submit the following by tomorrow, July 28, 2020: LIC601 Identification and Emergency Information; Pre-placement Appraisal; hospital discharge document and/or After Visit Summary; Re-appraisal; Admission Agreement; doctor's order of medications; Medication Administration Record.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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