015600073-10-6-2020-15-AS-KHOS-BU7MRY-20201008095105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600073
Report Date: 10/06/2020
Date Signed: 10/06/2020 03:45:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/29/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200929125835

FACILITY NAME:	CASA SANDOVAL		FACILITY NUMBER:	015600073
ADMINISTRATOR:	ROSANA FRIAS		FACILITY TYPE:	740
ADDRESS:	1200 RUSSELL WAY		TELEPHONE:	(510) 727-1700
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	99	CENSUS: 56	DATE:	10/06/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Rosana Frias/Associate Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff refused to release resident's (R1) records to authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo called and spoke with Associate Executive Director Rosana Frias. LPA explained that the reason for the call is to inform that a complaint has been received. LPA further explained that due to the Shelter in Place Order and management directive to telework, the notification is done via televisit.

LPA conducted interviews. LPA also obtained copies of R1's following documents: LIC601 Identification and Emergency Notification; Durable Power of Attorney; FedEx receipt

Ms. Frias indicated they received a letter dated September 23, 2020 from the authorized representative requesting for copies of resident's (R1) records. On September 28, 2020, she spoke with W1 to verify how they want to have the documents sent out. On that same day, the documents were mailed out via FedEx.

...............continued next page

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200929125835

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA SANDOVAL	FACILITY NUMBER: 015600073
	VISIT DATE: 10/06/2020

NARRATIVE

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Copy of FedEx receipt confirmed Ms. Frias' statement. LPA interviewed W1 who stated the documents were received on September 29, 2020.

Based on the information gathered, the allegation of staff refused to release resident's (R1) records to authorized representative is closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the complaint is dismissed.

Exit interview conducted and copy of this report provided via e-mail to Ms. Frias.

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

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