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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 08/03/2023
Date Signed: 08/03/2023 06:35:45 PM


Document Has Been Signed on 08/03/2023 06:35 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: 65DATE:
08/03/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria David/Business Office SpecialistTIME COMPLETED:
06:35 PM
NARRATIVE
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On this day, August 3, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230801150316). LPA met with Business Office Specialist Maria David who called Operations Regional VP Phii Atlman. LPA informed the reason for visit.

LPA toured the facility with Maria David. LPA inspected the 1st, 2nd, 3rd, 4th and 5th floors including but not limited to common areas and dining room and activity areas on the 1st and 2nd floors, salon, housekeeping, electrical and art rooms, patio. LPA randomly selected total of 12 residents apartments on 2nd, 3rd, 4th and 5th floors,

LPA observed the following:
-at 1:03 pm, cuticle remover, scissors, Tide Ultra Concentrated Liquid Soap, cleaning and salon supplies in cabinets/drawers without lock in unlocked salon on the 1st floor.
-at 1:07 pm. professional strength glue, scissors, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room.
-at 1:12 pm, cleaning supplies in unlocked housekeeping room on the 2nd floor.
-at 1:30 pm and 1:50 pm, "Oxygen in Use" sign on resident's apartments doors on the 3rd floor.
-at 3:00 pm, resident (R1) does not have LIC602A Physician's Report and Pre-admission Appraisal on file. LPA verified and two staff confirmed R1 does not have these documents.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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: 08/03/2023
NARRATIVE
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-at 3:10 pm, LPA also observed R2's Lic602A Physician's Report indicated R2 has dementia but can administer own medications but doctor's notes with same date as that on LIC602 showed R2 can not determine needs for medications.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with

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: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/03/2023 06:35 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
-This requirement is not met as evidenced by:
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Staff locked the rooms.
In addition, an in-service training to be conducted and copy of training topic with attendees signatures to submitted by 8/03/23.
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-Based on observation, the licensee did not comply with the section above for having cabinets, drawers, storage without lock and/or unlocked where cleaning, art and salon supplies and scissors are kept which pose 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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/03/2023 06:35 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.....
-This requirement is not met as evidenced by:
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Administrator to obtain medical assessment, and submit copy by 8/17/23.
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-Based on records review, the licensee did not comply with the section above for not having medical assessment and/or LIC602A for R1 which poses potential health and/or safety risks to person in care.
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Type B
08/17/2023
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria...
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Administrator to have the document completed and submit copy.
In addition, administrator to ensure that in the future, a pre-admission appraisal is completed before admission.
Proof to be submitted by 8/17/23,
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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 without pre-admission appraisal which poses oses potential health and/or safety risks to person 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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/03/2023 06:35 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87458(c)

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87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.

-This requirement is not met as evidenced by
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Administrator to have the documents updated, and submit copies by 8/17/23.
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-Based on records review, the licensee did not comply with the section above for R2's medical assessment indicating R2 has dementia but can administer medications which is not consistent with doctor's note indicating R2 can not determine need for medications,
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Type B
08/17/2023
Section Cited
CCR87618(b)(3)(B)

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87618 Oxygen Administration - Gas and Liquid (b).., the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements:(B)"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
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Administrator to have a sign posted,and submit picture by 8/17/23.
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-Based on observation, the licensee did not comply with the section above for not having the sign posted in appropriate place which poses a potential risk 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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5