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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200851
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:14:47 PM

Document Has Been Signed on 02/24/2023 02:14 PM - It Cannot Be Edited

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: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: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Allen Gacusan, Lead StaffTIME COMPLETED:
02:30 PM
NARRATIVE
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On 02/24/2023 at 1:25PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with lead staff, Allen Gacusan and explained the purpose of the visit. Administrator, Lisset Dizon arrived at approximately 1:40PM.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas and kitchen. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

LPAs observed the following deficiencies during today's POC visit:

-LPA observed that the side yard gate was locked with a medal hook.

An immediate civil penalty of $500.00 will be assessed on today's date for a (locked gate) Fire Clearance violation 80020(a).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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: SANDLEWOOD CARE HOME
FACILITY NUMBER: 019200851
VISIT DATE: 02/24/2023
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Continue from LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/03/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 02:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 02/24/2023 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANDLEWOOD CARE HOME
FACILITY NUMBER: 019200851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020(a)

Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above by having a medal hook whiched locked gate which was not originally approved by the fire department which poses an immediate health and safety risk to the clients in care.
POC Due Date: 02/25/2023
Plan of Correction
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 Lead staff removed the medal hook lock during inspection. deficiency cleared during visit.
$500 Civil Penalty was assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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