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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 12/15/2023
Date Signed: 12/15/2023 05:17:22 PM


Document Has Been Signed on 12/15/2023 05:17 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:HENRY, CAYIAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 68DATE:
12/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Cayia Henry/Executive DirectorTIME COMPLETED:
04:30 PM
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On this day, 12/15/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management as a follow-up on the Death Report received by the Department on 12/11/23. Report indicated that when caregiver (S1) arrived at R1's apartment to assist with feeding for dinner, S1 noted that R1 was unresponsive. Med-tech (S2) was gathering vital signs and noted that there was no pulse noted. Wellness Nurse (S3) called 9-1-1 and called the closest kin. Report also indicated that R1 returned to the facility on 12/08/23 from post acute.

LPA obtained copies of including but not limited to the following documents: Notice of Transfer/Discharge from post acute; LIC602A Physician's Report; LIC9172 Functional Capability Assessment dated 12/08/23; Progress Notes, LPA conducted interviews.

No deficiency cited on this day,

Exit interview conducted 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: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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