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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200851
Report Date: 03/02/2024
Date Signed: 03/02/2024 06:59:13 PM

Document Has Been Signed on 03/02/2024 06:59 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: 4DATE:
03/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Lisset Dizon/Administrator TIME COMPLETED:
07:00 PM
NARRATIVE
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At 1:25 p.m. on this day, March 2, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met Lisset Dizon, administrator, and informed the reason for visit. LPA also met with staff, Maricel Gacusan and Allan Gacusan.

Facility has LIC808 Mitigation Plan but has not submitted the a new LIC9282 Infection Control Plan.

LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, garage, front, side and backyard. Food were inspected and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in the common bathroom on the second floor was tested, and measured at 109.9 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted February 3, 2024. Fire extinguishers checked, observed fully charge with tags showed serviced March 15, 2023.

LPA reviewed 5 staff and 4 residents files, and interviewed 2 residents and 2 staff. Medications checked, and compared with records and doctor's orders. Residents' P&I checked and compared with last recorded balance.

LPA observed the following:
-at 2:00 p.m., 3 out of 4 residents' beds have no mattress pads.
-at 3:30 p.m., staff (S4 and S5) First Aid certificates on file expired 2/08/24.

...........continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2024
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: 03/02/2024
NARRATIVE
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-from 3:40 p.m.- 4:10 p.m., residents (R2, R3 and R4) do not have Pre-admission Appraisal.
-at 4:30 p.m,, all 4 residents do not have LIC9172 Functional Capability Assessments.

Administrator to submit copies of the following current/updated documents by March 16, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
3. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with administrator.

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: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/02/2024 06:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/02/2024 at 06:22 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: 03/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above 3 out of 4 residents' beds with no mattress pads which pose a potential personal rights risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
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4
Corrected.
Staff put mattress pads.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff (S4 and S5) First Aid certificates expired which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
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Administrator to have the staff register and complete the training. Copies of certificates to be submitted 3/16/24.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/02/2024 06:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/02/2024 at 06:22 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: 03/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 residents with no LIC9172 which pose potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
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Administrator to do the LIC9172 and self-certify they are completed. Seff-certification to be submitted by 3/16/24.
Type B
Section Cited
CCR
85068.1(b)
85068.1 Admission Procedures
(b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the sectiion above in R2, R3 and R4 not having Pre-admission Appraisal which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
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Administrator to do the Pre-admission Appraisal and self-certify they are completed. Proof to be submitted by 3/16/24.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2024


LIC809 (FAS) - (06/04)
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