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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 10/20/2021
Date Signed: 10/20/2021 05:41:03 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 SANDOVALFACILITY NUMBER:
019200922
ADMINISTRATOR:APOLINARIO C. GOZONFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: 53DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Associate Executive Director Rosana FriasTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmund conducted an unannounced infection control annual inspection. LPA met with Associate Executive Director (AED) Rosana Frias and informed the purpose of visit.

Facility is a seven story building, 2nd and 3rd floors of which house assisted living residents. Facility has a completed COVID-19 mitigation plan that was approved on April 12, 2021.

LPA inspected the facility inside and out with Rosana Frias. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe; surgical masks and disposable gloves are readily available at the front desk. . Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. LPA observed COVID-19 physical distancing signages posted in common areas. Infection control designated leader is the wellness coordinator.

Medications are centrally stored in the medication room attended by med-techs, wellness coordinator and wellness director. Adequate supply of centrally stored PPEs was observed. There were at least 7 days of nonperishable and 2 days of perishable foods. Facility maintains daily log of freezer temperature. Fire extinguisher in the kitchen was observed fully charged and tag showed serviced March 29, 2021. Smoke and carbon monoxide detectors were operational. Facility room temperature was tested and measured at 69 degrees Fahrenheit.

LPA randomly selected 5 resident rooms on the second floor and 5 resident rooms on the third floor for inspection.

......continued on LIC809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (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)
Page: 1 of 5
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
NARRATIVE
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LPA observed the following:
1. Three cans of gallon size expired prunes (expiration date: June 2020) and 1 of the cans was rusted.
2. No handwashing signage in the bathrooms and trash cans with no lids in resident's rooms including the shared room.
3. No updated visitor's poster on the entrance door.
4. No cough and sneeze etiquette posters.

LPA requested for copies of the following updated documents to be submitted to Community Care Licensing (CCL) by November 3, 2021:
1. LIC500 Personnel Report
2. LIC308 Designation of Facility Responsibility
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance coverage

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Rosana Frias.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (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)
Page: 2 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited

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87555 General Food Service Requirements:
(a)....... All food shall be selected, stored, prepared and served in a safe and healthful manner.

-This requirement is not met as evidenced by;
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-Based on inspection, the licensee did not comply with the section above. LPA observed 3 cans of expired prunes which pose immediate health 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5