019200922-10-20-2021-15-AS-ADEO-C7Z2WJ-20211020174538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 10/20/2021
Date Signed: 10/20/2021 05:45:44 PM

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:	CASA SANDOVAL		FACILITY NUMBER:	019200922
ADMINISTRATOR:	APOLINARIO C. GOZON		FACILITY TYPE:	740
ADDRESS:	1200 RUSSELL WAY		TELEPHONE:	(510) 727-1700
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	99	CENSUS: 53	DATE:	10/20/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Associate Executive Director Rosana Frias		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual/Injury Incident Reports (UIRs) for residents (R1, R2, R3 and R4) submitted by the facility to the Department. LPA met with Associate Executive Director Rosana Frias and informed the purpose of visit. LPA also met and spoke with Wellness Director/LVN Valentine Mathangani.

UIRs indicated the following:
1. Resident (R1)

October 1, 2021 - Home health was providing routine wound care to R1. Wound not improving. Wound was cleansed and treated by the nurse before resident was transferred to the hospital for further evaluation. R1 remains out of the community at the time of the report.

2. Resident (R2)

September 25, 2021 - case manager checked at around 5:30 pm and found R2 unresponsive. 9-1-1 was activated and R2 was transported to the hospital. R2 was discharged back to the facility with no new orders; frequent checks initiated

3. Resident (R3)

October 3, 2021 - R3 called Hayward Police Department (HPD) for assistance at around 3:30 am, because R3 wants to go to the hospital and talk to her doctor. HPD took R3 to John George. Case manager and R3's physician were notified.

4. Resident (R4)

October 1, 2021 - R4 was noted to have swelling on face and puffy eyelids. Staff called 9-1-1 and R4 was brought to the emergency. R4's POA and physician notified.

.....continued on LIC809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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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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: CASA SANDOVAL	FACILITY NUMBER: 019200922
	VISIT DATE: 10/20/2021

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LPA conducted interviews and obtained the following documents for R1, R2, R3 and R4: LIC602A Physician's Report; Appraisal; hospital discharge document. LPA also obtained copies of home health visit notes for R1. According to Rosana Frias and Valentine Matangani, R1 and R4 did not return to the facility.

LPA to review the documents obtained. A follow-up visit will be conducted if warranted.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC809 (FAS) - (06/04)

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