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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200851
Report Date: 08/16/2022
Date Signed: 08/16/2022 06:55:17 PM

Substantiated


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
02/15/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220215113831
FACILITY NAME:SANDLEWOOD CARE HOMEFACILITY NUMBER:
019200851
ADMINISTRATOR:DIZON, LISSET RFACILITY TYPE:
735
ADDRESS:28024 SANDLEWOOD DRTELEPHONE:
(510) 940-8260
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: DATE:
08/16/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lisset Dizon/Administrator TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Facility staff failed to notify conservator about resident's (R1) bruise.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation, and close the complaint. LPA met with care staff, Abeto Lucenesio, informed the reason for visit, and requested to call Lisset Dizon. administrator, who arrived after several minutes.

During the course of investigation, LPA obtained copies of resident's (R1) documents including but not limited to LIC601 Identification and Emergency Information, LIC602 Physician's Report, Behavior Tracking Log, Individual Program Plan (IPP), Individual Service Plan (ISP), hospital documents and incident report. LPA conducted interviews.


......continued next page (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
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 5
Control Number 15-AS-20220215113831
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: SANDLEWOOD CARE HOME
FACILITY NUMBER: 019200851
VISIT DATE: 08/16/2022
NARRATIVE
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LPA interviewed staff (S1 and S2) who stated R1 has scratching behavior. LPA also interviewed the administrator of the facility where R1 moved, and confirmed that R1 has skin picking behavior. Review of records confirmed R1 has skin picking behavior.

R1's family member (FM) indicated that the administrator did not inform FM of the bruise and only learned about it when R1 went to the doctor

Administrator stated R1 started skin picking when R1 learned R1 is moving out of the facility and that she did not inform R1's responsible person of the bruise.

Based on information gathered, the allegation is closed as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met..

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and correction were discussed with Lisset Dizon.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220215113831
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: SANDLEWOOD CARE HOME
FACILITY NUMBER: 019200851
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited
CCR
80061(f)
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80061 Reporting Requirements
(f) The items specified in (b)(1)(A) through (H) shall also be reported to the client's authorized representative, if any.

-This requirement is not met as evidenced by:
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R1 no longer lives in the facility.
Administrator to read the Regulations and self-certify she understood and will comply. Proof to be submitted by 8/30/2022.
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-Based on interviews and records review, the licensee did not comply with the setion above for not notifying R1's responsible person when R1 sustained bruise which posed potential health and personal rights 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/15/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220215113831

FACILITY NAME:SANDLEWOOD CARE HOMEFACILITY NUMBER:
019200851
ADMINISTRATOR:DIZON, LISSET RFACILITY TYPE:
735
ADDRESS:28024 SANDLEWOOD DRTELEPHONE:
(510) 940-8260
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: DATE:
08/16/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lisset Dizon/Administrator TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Resident sustained unexplained bruise.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation, and close the complaint. LPA met with care staff, Abeto Lucenesio, informed the reason for visit, and requested to call Lisset Dizon. administrator, who arrived after several minutes.

During the course of investigation, LPA obtained copies resident's (R1) documents including but not limited to LIC601 Identification and Emergency Information, LIC602 Physician's Report, Behavior Tracking Log, Individual Program Plan, Individual Service Plan. hospital discharge documents, incident reports. LPA conducted interviews.

LPA interviewed staff (S1 and S2) who stated R1 has scratching behavior. LPA also interviewed the administrator of the facility where R1 moved and confirmed that R1 has skin picking behavior.

....continued next page (9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220215113831
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: SANDLEWOOD CARE HOME
FACILITY NUMBER: 019200851
VISIT DATE: 08/16/2022
NARRATIVE
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Review of R1's IPP and Behavior Tracking Log confirmed R1 has skin picking behavior.

LPA interviewed residents (R2 and R3) who stated they never observed any staff hitting and/or being physical with R1 and other residents. Staff (S1 and S2) denied hitting R1 and other residents and stated that R1 sustained bruise from scratching what started as a pimple. LPA tried to interview R1 but was unable to obtain information.

Based on all the information gathered, and LPA unable to obtain information from R1, 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.

No deficiency cited.

Exit interview conducted and copy of report provided to Lisset Dizon.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5