<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:43:29 PM


Document Has Been Signed on 12/22/2023 03:43 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: DATE:
12/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Cayia Henry/Executive DirectorTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, 12/22/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management as a follow-up on the Death Reports and Unusual Incident Reports (UIRs) received by the Department. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit.

Reports indicated the following:
1. Resident (R1) Death Report
Report indicated R1 passed away on 5/09/23 with cause of death unknown. R1 was previously sent to the hospital for increased confusion and complaints of left hip pain. R1 expired at the hospital. R1's son called the facility to inform that R1 passed away..
2. Resident (R2) Death Report
Report indicated R2 passed away on 7/17/23. R2 was found unresponsive, no pulse noted and pale in color. Med-tech on duty called 9-1-1 right away. R2 had a fall on 7/10/23 but refused to paramedics to be transferred to ER. R2 refused paramedics again on 7/12/23; was sent via 9-1-1 for an x-ray appointment on 7/14/23, but refused to stay in the hospital for treatment. R2 again refused to be sent out on 7/16/23 due to distended abdomen,
3. Resident (R3) Unusual Incident Report (UIR)
UIR indicated R3 had un-witnessed fall on 12/23/23 and was noted with a bump on the side of R3's head and abrasion on the left knee. 9-1-1 was called and R3 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified.
4. Resident (R4) UIR
UIR indicated R4 was seen lying on the floor screaming for help and complaining of pain of left side of leg and head. R4 was conscious and responsive. 9-1-1 was called and R2 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 3


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: 12/22/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed residents' files and obtained copies of documents including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal; facility notes; Post-fall Evaluation; hospital discharge documents. LPA conducted interview.

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

Deficiencies and plan and proof of correction were discussed with ED.

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: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/22/2023 03:43 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: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87463(a)

1
2
3
4
5
6
7
87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental,.....
1
2
3
4
5
6
7
R1 is no longer at the facility.

Executive Director stated she'll have all the files double checked and ensure records are updated. Self-certification to be submitted by 1/05/23.
8
9
10
11
12
13
14
.....and social condition.
-This requirement is not met as evidenced by:
- Based on records review and interview, the licensee did not comply with the section above for not doing a re-appraisal or updating Care Plan after R1 had multiple falls in few months.
8
9
10
11
12
13
14
Type B
01/05/2024
Section Cited
CCR87211(a)(1)(D)

1
2
3
4
5
6
7
87211 Reporting Requirements
(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the event.(D)Any incident which threatens the welfare, safety or health of any resident,...
1
2
3
4
5
6
7
R2 is no longer at the facility.

Executive Director stated an in-service training for the Wellness Department will be conducted to ensure enforcement of Reporting Requirements. Copy of in-service to be submitted by 1/05/23.

8
9
10
11
12
13
14
-This requirement is not met as evidenced by:
- Based on records review and interview, the licensee did not comply with the section above for not submitting incident report for R2 which poses a potential health, safety and/or personal rights risks to person in care,
8
9
10
11
12
13
14
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: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3