019200922-2-15-2024-15-AS-BFOG-D5HTSV-20240522145942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 02/15/2024
Date Signed: 02/15/2024 06:29:51 PM

Unsubstantiated

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
02/16/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220216145850

FACILITY NAME:	CASA SANDOVAL		FACILITY NUMBER:	019200922
ADMINISTRATOR:	APOLINARIO C. GOZON		FACILITY TYPE:	740
ADDRESS:	1200 RUSSELL WAY		TELEPHONE:	(510) 727-1700
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	170	CENSUS: 83	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	06:00 PM
MET WITH:	Cayia Henry/Executive Director		TIME COMPLETED:	06:35 PM

ALLEGATION(S):

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-Facility is isolating residents.

-Facility is delivering residents meals cold.

-Facility is not providing activities for residents.

INVESTIGATION FINDINGS:

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On this day, February 15, 2024, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director Cayia Henry, and informed the reason for visit.

During the course of investigation, LPA obtained copies of resident roster and staff schedule. On 2/25/22,. LPA interviewed staff (S1) and 3 residents. LPA also reviewed the facility Covid-19 cases history, spoke with Associate Executive Director (AED), and obtained information regarding Local Public Health (LPH) Nurse recommendations during the time facility had outbreak.

.....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
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)

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Control Number 15-AS-20220216145850

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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Allegations:
-Facility is isolating residents.
-Facility is not providing activities for the residents.
R1 stated the facility dining and activity rooms were closed and does not understand why the facility was quarantined. The other 2 residents (R2 and R3) stated they were not bothered when dining and activity rooms were closed during the outbreak and R3 stated it is for the health and safety of everyone. Staff (S1) stated the dining and activity were closed per recommendation by Public Health. Review of information obtained from AED showed that it was the LPH recommendation to close the dining and activity room during outbreak.

Allegation: Facility is delivering residents meals cold.
R1 stated the food delivered to his room was cold. S1 stated that during outbreak, meals were delivered to each of the resident in their room. Some of the residents were still sleeping when meals were delivered and caregivers warm their food when residents were ready to eat. R2 stated if her food was cold, it’s not a problem as caregiver warms it. R3 stated sometimes the food was not warm but it’s not a problem because he can warm it in his microwave.

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

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
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)

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