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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:54:06 PM


Document Has Been Signed on 03/22/2024 03:54 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: 93DATE:
03/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cayia Henry/Executive Director TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. UIR indicated that at 12:26 p.m. on February 8, 2024, Reflections Coordinator (S1) was notified by care manager (staff) that there were discrepancies with residents' narcotic medications. After S1 confirmed that the medications in the containers were incorrect, S1 reported to the Wellness Director (WD) who in turn reported to Executive Direction (KED) Cayia Henry. WD and ED immediately launched an investigation and in-service on narcotic count and recognition initiated to all med-techs. ED notified Local Law Enforcement, and Controlled Substance Count documented.

On this day, March 22, 2024, LPA conducted interview and obtained copies of documents.

No deficiency cited.

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: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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