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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200851
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:24:01 PM

Document Has Been Signed on 11/16/2021 03:24 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:
11/16/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lisset Dizon/AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced Health & Safety inspection as a result of the Department receiving a priority 2 complaint (15-AS-20211112145534). LPA met with Lisset Dizon, administrator.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. There are no accessible bodies of water observed. Indoor and outdoor passageways were free of obstruction. Hot water temperature was tested in one of the bathrooms and measured at 137.8 degrees Fahrenheit.

Deficiency is cited from Title 22 California Code of Regulations (see 809D).

Deficiency and plan and proof of correction were discussed with Lisset Dizon. Any repeat violations within 12-month period may result in civil penalty.

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: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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Document Has Been Signed on 11/16/2021 03:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2021 at 03:07 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: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2021
Section Cited
CCR
80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies
(e)...(1)Hot water temperature controls shall be maintained to automatically regulate temperature of hot water ......of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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Administrator to do the following and submit proof by 11/17/2021:
1. Adjust the temperature immediately.
2. In-service staff to ensure temperature is maintained within Regulations range,
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-This requirement is not met as evidenced by:

-Based on observation, the licensee did not comply with the section above. Hot water temperature was measured at at 137.8 degrees Fahrenheit which poses immediate safety risks to persons 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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