015600073-10-20-2021-15-AS-KHOS-C9RLZ3-20211216081117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600073
Report Date: 10/20/2021
Date Signed: 10/20/2021 05:56:01 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
06/01/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200601140908

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:	0	CENSUS: 53	DATE:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Associate Executive Director Rosana Frias		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Resident eloped from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived at the facility unannounced to deliver the findings on the above allegation. LPA met with Associate Executive Director Rosana Friasand informed the purpose of visit.

It was alleged that for 3 consecutive days in May 2020, R1 who has dementia, tried to leave the facility early morning. On the third incident on early morning of May 31, 2020, R1 ran out of the facility. It was further alleged that the facility did not ensure that resident with dementia was supervised.

During the course of investigation, LPA obtained copies and reviewed R1’s documents including but not limited to medical records, LIC622 Centrally Stored Medication and Destruction Records, appraisal and incident reports. LPA also interviewed staff (S1, S2 and S3) and R1’s family member (FM).

.....continued next page (LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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-20200601140908

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: 10/20/2021

NARRATIVE

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Documents obtained by LPA from the facility and R1's medical records revealed R1 was diagnosed with dementia on January 2020. R1’s family member (FM) indicated this information was relayed to S1 and that R1 was prescribed medication.

Review of 3 Unusual Incident Reports (UIRs) indicated the incidents happened on May 29, 2020, May 30, 2020 and May 31, 2020. The May 31, 2020 UIR revealed R1 had another episode of anxiety attack, screaming for help at around 4:00 am and forcefully opened the front door and ran out of the facility which LPA confirmed with staff, S2 and S3. S2 indicated R1 was brought by the paramedics to the hospital. Review of hospital After Visit Summaries indicated diagnosis as dementia with behavioral disturbance. Review of LIC622 Centrally Stored Medication and Destruction Record confirmed R1 had medication that was started January 2020 which LPA confirmed with S1 who indicated the medication was for memory. S1 stated R1’s diagnosis of dementia may have been communicated to her by FM. S3 confirmed that R1 was anxious and agitated during May 29, 2020 and May 30, 2020 incidents. Records review revealed the facility reassessed R1 in February 2020; however, it did not address the dementia related care needs nor a reassessment done after the 3 incidents happened in May 2020 to meet R1's care and supervision needs.

Based on records review and interviews, the preponderance of the evidence standard has been met, therefore allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of corrections by plan of correction due date may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC421IMs Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200601140908

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2021 Section Cited CCR 87705(c)(5)(A)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) .....(5) Each resident with dementia shall .......(A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.	1 2 3 4 5 6 7	R1 is no longer in the facility. Associate Executive Director to do the following: 1. Have the staff register for training with a certified vendor. Proof of registration to be submitted by 10/21/2021.
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: -Based on interview and records review, the licensee did not comply with the section cited above. R1 was not provided appropriate assistance to meet the needs that lead to R1 eloping from the facility.	8 9 10 11 12 13 14	2. Copies of training certificates to be submitted by 11/03/2021.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC9099 (FAS) - (06/04)

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