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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 10/10/2022
Date Signed: 10/10/2022 06:33:28 PM


Document Has Been Signed on 10/10/2022 06:33 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:CASA SANDOVALFACILITY NUMBER:
019200922
ADMINISTRATOR:APOLINARIO C. GOZONFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 50DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rosana Frias/Associate Executive Director TIME COMPLETED:
06:40 PM
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Licensing Program Analysts (LPAs) Alicia Delmundo and Liridon Fici 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, 3rd, 4th and 5th floors of which house assisted living residents. Facility has an LIC808 Mitigation Plan on file; however, the new Infection Control Plan and Monkeypox Infection Control Plan have not been submitted. LPA verified and AED stated the staff were fit tested for N95 respirator over a year.

LPAs inspected the facility inside and out with AED. LPAs observed screening station located near the front entrance with visitor's log, hand sanitizer and digital Accushield COVID-19 screening/check-in system. Surgical masks and disposable gloves are readily available at the front desk .Residents are screened for COVID-19 symptoms and temperature checked daily. Adequate supply of centrally stored PPEs was observed.

There were at least 7 days of nonperishable and 2 days of perishable food supplies. Facility maintains daily log of freezer and refrigerator temperatures. Fire extinguisher in the kitchen was observed fully charged and tag showed serviced May 4, 2022. Hot water temperature in one of the common bathrooms was tested and measured at 116.2 degrees Fahrenheit.

LPAs randomly selected 4 resident rooms on the 4th and 5th floors 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: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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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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: 10/10/2022
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LPAs observed the following:
1. No "Wear Mask" poster on the front entrance.
2. No hand washing posters in the common bathrooms/toilets.
3. No COVID-19 physical distancing signages in common areas.
4. Construction equipments/tools and chemicals in unlocked room on the ground floor.

The following updated/current documents to be submitted by October 24, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Infection Control Plan and Monkeypox Infection Control Plan

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency and plan and proof of correction were discuss with AED.

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: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/10/2022 06:33 PM - It Cannot Be Edited

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: 10/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Facility has residents with dementia and the room with construction tools/equipments and chemicals was unlocked which poses an immediate safety risk to persons in care.
POC Due Date: 10/11/2022
Plan of Correction
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AED locked the room immediately.
In addition, AED to conduct in -service training and submit proof by 10/11/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5