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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600073
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:14:26 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
01/29/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20200129172211
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: 59DATE:
10/27/2020
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Neglect/lack of supervision – resident (R1) developed stage 3 pressure injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo called and spoke with Associate Executive Director Rosana Frias. LPA explained that the reason for call is to deliver the findings on the above allegation. LPA further explained that due to the Shelter in Place Order and management directive to telework, the deliverance is done via televisit.

During the course of investigation, the Department obtained the following documents: medical records; death report; death certificate; LIC601 Identification and Emergency Information; Admission Agreement; Physician's Report; doctor's order of medications; Medication Administration Records; appraisal; p\Personal Care Levels of Care Determination. Copies of resident rosters and staff schedule were also obtained. Facility staff (S1, S2 and S3), Associate Executive Director Rosana Frias, Wellness Director-RN Bernadette Rosales and resident (R1) were interviewed. W1 and W2 who have no direct affiliation with the facility but have provided care and have knowledge of the care provided respectively were also interviewed.
...........continued next page
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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 4
Control Number 15-AS-20200129172211
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: 10/27/2020
NARRATIVE
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Photos submitted by reporting party (RP) and reviewed by the Department showed the pressure injuries likely at stage 3, stage 2 and stage 1. RP claimed the pictures were taken November 24, 2019 but it was unclear when the pictures were taken. The Department was unable to clarify RP’s 3rd party information who may have knowledge of the pressure injuries. The medical evidence showed that R1 was diagnosed with stage 2 pressure injury to her bottom which deteriorated around April 2020. Home Health began on April 2020 and pressure injury was determined to be unstageable at that point. From January 2020 to April 2020, the facility appeared to actively coordinate or attempt to coordinate proper medical care. Facility and medical records first documented the pressure injury around January 2020. Staff interviewed (S1, S2, S3 and Wellness Director) indicated the pressure injury was observed around January 2020, February 2020. W1 and W2’s statements corroborated with the medical records.

Based on all the information obtained, the allegation is closed as 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 copy of this report provided to Ms. Frias via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
01/29/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20200129172211

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: 59DATE:
10/27/2020
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/lack of care and supervision resulting in resident (R1) developing/sustaining rashes.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo called and spoke with Associate Executive Director Rosana Frias. LPA explained that the reason for call is to deliver the findings on the above allegation. LPA further explained that due to the Shelter in Place Order and management directive to telework, the deliverance is done via televisit.

During the course of investigation, the Department obtained the following documents: medical records; LIC601 Identification and Emergency Information; Admission Agreement; Physician's Report; doctor's order of medications; Medication Administration Records; appraisal; personal Care Levels of Care Determination. Copies of resident rosters and staff schedule were also obtained. Facility staff (S1, S2 and S3), Rosana Frias and Wellness Director-RN Bernadette Rosales and resident (R1) were interviewed. On January 17, 2020, R1 was diagnosed with inflammatory condition of the skin folds aggravated by friction, heat and lack of air circulation. By choice, R1 preferred to be in bed under a blanket in a warm room.
..........continued next page
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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 4
Control Number 15-AS-20200129172211
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: 10/27/2020
NARRATIVE
1
2
3
4
5
6
7
8
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10
11
12
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32
Medical consultation was sought and the rashes were treated. Medical records did not present this as an ongoing or continued medical problem.

Based on the information gathered, the allegation 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 to Ms. Frias via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4