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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200851
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:58:59 PM

Document Has Been Signed on 03/10/2025 03:58 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/
DIRECTOR:		DIZON, LISSET RFACILITY TYPE:
735
ADDRESS:28024 SANDLEWOOD DRTELEPHONE:
(510) 940-8260
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 4DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Allan Gacusan/Staff and
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, March 10, 2025, at 12:55 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with staff, Allan Gacusan and Maricel Gacusan. LPA called and spoke over the phone with Lisset Dizon, administrator (ADM), and informed the reason for visit. ADM gave permission to Allan Gacusan to be with LPA in touring the facility. ADM arrived at around 1:50 pm.

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. Cabinets for sharps and cleaning supplies and closet where residents medications are centrally stored were observed locked.

Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Hot water temperature in the common bathroom on the second floor was tested, and measured at 109.9 degrees Fahrenheit. Facility conducts fire and earthquake drills every quarter with records showed last conducted 2/05/25 and 1/06/25 respectively. Fire extinguishers checked, observed fully charge with tags showed serviced 3/04/25.

LPA reviewed 5 staff and 4 residents files. Medications checked, and compare with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&I checked and compared with last recorded balance.


...........continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 03/10/2025
NARRATIVE
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LPA observed the following:
-at 1:11 pm, derailed closet door with pop corn ceiling dented and bits of the ceiling particles in the closet railing in one of the resident's rooms.
-at 1:17 pm, broken patio chairs in the backyard.
-at 3:00 pm, residents, R1 and R4 have doctor's order dated 3/28/24 each for 1 medication but facility does not have the medications nor have the discontinued orders.

Administrator to submit copies of the following current/updated documents by March 24, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. 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 penalty.

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

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: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2025 03:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/10/2025 at 03:29 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: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and records review, the licensee did not comply with the section cited above in R1 and R4 having doctor's orders dated 3/28/24 each for 1 medication but facility does not have the medications nor have the discontinued orders. These pose an immediate health and/or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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2
3
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Administrator to check with the residents' doctors if the medications are no longer needed and obtain discontinued orders; otherwise, obtain the medications. Proof to be submitted by 3/11/25.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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3
4
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: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2025 03:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/10/2025 at 03:29 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: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in the following which pose a potential safety and/or personal rights risks to persons in care: derailed closet door with ceiling dented and railing with with ceiling particles; broken patio chairs
POC Due Date: 03/24/2025
Plan of Correction
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Administrator to do the following and submit proof by 3/24/25.
1. Have closet door fixed, ceiling repaired and railing cleaned.
2. Discard the patio chairs.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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