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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600073
Report Date: 08/12/2021
Date Signed: 08/12/2021 03:12:51 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:0CENSUS: 52DATE:
08/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Apolinario 'Paul' Gozon/Executive DirectorTIME COMPLETED:
03:25 PM
NARRATIVE
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During investigation of complaint (15-AS-20190617162656) and upon review of resident’s (R1) documents, Licensing Program Analyst (LPA) Delmundo learned that R1’s who has dementia diagnosis didn’t have Appraisal/Needs and Services Plan and Personal Care Levels of Care Determination for 2018 and 2019. LPA verified with Associate Executive Director Rosana Frias who indicated they don’t have these documents and they didn’t do reappraisal.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Executive Director Apolinario 'Paul' Gozon
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2021
Section Cited

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87705 Care of Persons with Dementia
(c).....(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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This requirement is not met as evidenced by:

-Based on records review and interview, the licensee did not comply with the section cited above by not doing reappraisal which posed potential health and safety risks to person 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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