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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 02/15/2024
Date Signed: 02/15/2024 06:26:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240212095317
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: 83DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cayia Henry/Executive DirectorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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-Facility staff do not ensure materials that pose danger are stored inaccessible to residents.

-Facility staff working in the kitchen do not observe food services sanitation practices.
INVESTIGATION FINDINGS:
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On this day, February 15, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit.

LPA obtained copies of staff schedule, resident roster and Activity Schedule for the month of February. LPA conducted inspection with ED.

Allegation: Facility staff do not ensure materials that pose danger are stored inaccessible to residents.
During inspection, LPA observed the following: hazardous construction materials, worn furniture, used matresses in the garage; scissors and salon supplies in unlocked cabinets in unlocked salon; unlocked housekeeping room on the 4th floor where cleaning supplies are kept

......continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20240212095317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/15/2024
NARRATIVE
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The preponderance of evidence has been met, therefore, the allegation is substantiated. A $250.00 civil penalty is assessed for repeat violation of Regulation section # 87309(a). First and second citations were issued on 8/03/23 and 10/04/23.

Allegation: Facility staff working in the kitchen do not observe food services sanitation practices.
LPA observed 2 kitchen staff (KS1 and KS2), one peeling a pineapple and one doing the dishes with both with long hair not wearing hairnets. Although both staff had their hair tied back, one of the staff's hair dangling.

Based on information obtained, the preponderance of evidence was met, therefore, the allegation is substantiated.

Deficiencies, plan and proof of corrections and civil penalty were discussed with ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Assessment, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20240212095317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2024
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 at evidence by:
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ED locked the salon and housekeeping room.
In addition, ED will do the following and submit proof by 2/17/24:
1. Have the garage cleaned
2. In-service the staff.
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- Based on observation, the licensee did not comply with the section above for the following which poses immediate risk to persons in care: housekeeping room and salon unlocked; hazardous materials and debris in the garage.
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Type B
02/29/2024
Section Cited
CCR
87555(b)(15)
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87555 General Food Service Requirements: (b)(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.
-This requirement is not met at evidence by:
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ED to in-service the staff and submit proof by 2/29/24.
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-Based on observation, the licensee did not comply with the section above in 2 kitchen staff not wearing hair nets which pose potential health and/or personal rights 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240212095317

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: 83DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cayia Henry/Executive DirectorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
-Facility has roaches.

-Facility inappropriately serving alcohol to residents.

-Staff drinking alcohol while at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
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12
13
On this day, February 15, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit.

LPA conducted inspection with ED. LPA obtained copies of staff schedule, resident roster and Activity Schedule for the month of February, list of residents attending Happy Hour, and Pest Control Invoices. LPA conducted interviews.

Allegation: Facility has roaches.
LPA interviewe staff and 6 out of 7 staff stated observing roaches. ED stated facility has roaches and facility is serviced by a pest control company to eradicate which LPA observed during inspection. LPA also obtained copies of Invoices for the services rendered by pest control company.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240212095317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/15/2024
NARRATIVE
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Allegation: Facility inappropriately serving alcohol to residents.
List of Activities includes Happy Hour once a week. ED stated Happy Hour is open to all residents; however, not a lot of residents come. There's residents who regularly join the Happy Hour and the staff who serve during Happy Hour has list of residents who are not to be given alcohol per doctor's order. If they are not sure, they give the resident a "mock cocktail". If there's a new resident who wants alcohol. the staff check with the doctor first; this statement was observed by LPA during Happy Hour as one ot the staff informed 1 of the resident. LPA interviewed the 3 staff, 2 of which stated they only serve alcohol to those who are on the list to be given. The staff only give maximum of 2 small cups which was confirmed by LPA upon observation. LPA reviewed 1 of the resident who is on the list allowed to be given alcohol, Record showed this resident does not have order from the doctor prohibiting the resident from alcohol consumption.

Allegation: Staff drinking alcohol while at the facility.
It was alleged that 3 staff (S1, S2 and S3) drink alcohol when at the facility. LPA interviewed S1, S2 and S3 who all denied the allegation. LPA interviewed other 7 staff, 6 of which stated not observing S1, S2 and S3 drinking alcohol when at the facility. LPA also interviewed 1 of residents family member who stated not observing any staff drinking alcohol.

Based on all information gathered, the 3 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240212095317

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: 83DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cayia Henry/Executive DirectorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Facility staff do not maintain passageways free from obstruction.
INVESTIGATION FINDINGS:
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2
3
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5
6
7
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10
11
12
13
On this day, February 15, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit.

LPA conducted inspection with ED. LPA inspected the garage,1st floor to 5t floor, randomly selected residents rooms for inspection and interviewed staff.

Three of the 4 staff interviewed stated not observing obstructions while 1 of the staff stated observing obstruction on the 7th floor which the Department does not have jurisdiction. LPA didn't observed any obstruction on exit doors, hallways and common areas. Therefore, the allegation is unfounded.

Exit interview conducted and copy of this report provided.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6