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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200851
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:39:38 PM

Document Has Been Signed on 06/14/2022 04:39 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: 6DATE:
06/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Lisset Dizon/AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in response to the Special Incident Reports (SIRs) for resident (R1) submitted by the facility to the Department. LPA introduced self to staff, Juliana Lucenesio and Abeto Lucenesio. LPA called and spoke with Lisset Dizon, administrator, over the phone and informed the purpose of visit. Administrator arrived after several minutes.

SIRs received for the past months indicated R1 AWOLed. On June 6, 2022, R1 had another incident of AWOL and R1 was brought to the hospital. R1 sustained injury on the forearm.

Earlier today, June 14, 2022, administrator informed LPA that R1 set fire outside R1's bedroom.

LPA discussed the circumstances of the R1's history, behaviors including but not limited to AWOL, property destruction, self-injurious behavior, Individual Service Plan/Behaviorist Assessments, Appraisal/Needs and Services Plan. Review of R1's Physician's Report showed R1 can not leave the facility unassisted.

LPA conducted inspection and observed auditory signals on exit doors. LPA conducted interviews.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). A $500 civil penalty is assessed on this day for repeat violation of section 80078(a) within 12 month period and will continue for $100.00 per day until corrected.

Deficiency, plan and proof of correction and civil penalty were discussed with Lisset Dizon.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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 06/14/2022 04:39 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/14/2022 at 04:10 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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited
CCR
80078(a)

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80078(a) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Administrator will resubmit a 3-day eviction along with supporting documents.

A $500 civil penalty is assessed.
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-Based on records review and interview, the licensee did not comply with section cited above. R1 who is unable to leave unassisted was able to leave the facility which posed immediate health and safety risks to person in care. This is a repeat violation within 12 month period. The first citation was issued on 7/21/2021.
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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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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