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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 01/19/2023
Date Signed: 01/19/2023 07:13:44 PM


Document Has Been Signed on 01/19/2023 07:13 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: 55DATE:
01/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rosana Frias/Associate Executive Director.TIME COMPLETED:
07:10 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management as a follow-up on the Unusual Incident Report (UIR) received by the Department. UIR indicated that on October 19, 2022, staff checked on resident (R1) in room and common areas around 9:10 am, and unable to locate R1. Staff immediately activated code silver. Executive Director checked the camera monitor and saw R1 leaving around 9:00 am. Staff followed the route R1 headed, and found R1. R1 was not on apparent distress.

LPA requested for copies of LIC602A Physician's Report which revealed R1 has dementia and wandering and sundowning behaviors, and can not leave the facility unassisted.

On this day, LPA observed the front door entrance's auditory device not working.

Deficiendies cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

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: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 01/19/2023 07:13 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited

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87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering......
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AED stated R1's care plan has been updated after the incident. In addition, AED to in-service the staff and submit copy with attendees signatures by 01/20/2023
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-This requirement is not met as evidenced by:

-Based on records review, the licensee did not comply with the section above for R1 who has dementia was able to leave the facility unnoticed which posed immediate safety risk to person in care.
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Type A
01/20/2023
Section Cited

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

-This requirement is not met as evidenced by
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AED had the Maintenance Director checked device immediately. In addition, AED to in-service the staff and submit copy with attendees signatures by 01/20/2023

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-Based on observation, the llicensee did not comply with the section above.for the auditory device on the front door not working 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2