019200922-9-26-2024-15-AS-ADEO-D9H6KV-20240926205321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 09/26/2024
Date Signed: 09/26/2024 08:53:31 PM

Document Has Been Signed on 09/26/2024 08:53 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 SANDOVAL		FACILITY NUMBER:	019200922
ADMINISTRATOR:	HENRY, CAYIA		FACILITY TYPE:	740
ADDRESS:	1200 RUSSELL WAY		TELEPHONE:	(510) 727-1700
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	170	CENSUS: 105	DATE:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Rosana Frias/Associate Executive Director		TIME COMPLETED:	08:15 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	Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Associate Executive Director (AED) Rosana Frias, and informed the reason for visit. Facility is a seven story building, the 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has LIC9282 Infection Control Plan, and updated copy provided to LPA on this same day. LPA inspected the facility inside and out with AED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, Life Enhancement area, lounge/bistro. theater, fitness center/room, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies rooms, laundry rooms on other floors were checked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept and observed within Regulations range. LPA randomly selected 10 residents rooms for inspection - 4 rooms on 2nd floor, 2 rooms on the 3rd floor, and 3 rooms each on 4th and 5th floors. Facility has carbon monoxide and smoke detectors that are in operating condition. Hot water temperature in one of the residents' bathroom on the 3rd floor was checked and measured at 114.6 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced April 4, 2024. Facility has evacuation chairs on stairwells. Facility conducts disaster drills and records showed last conducted August 26, 2024. LPA reviewed 5 staff and 6 residents files, and interviewed 4 residents. ....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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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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: 09/26/2024

NARRATIVE

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LPA observed the following:
-at 1:44 pm, razor, hair developer, perming agent, waving lotion, anti fungal wash and screw driver in unlocked drawers in unlocked salon.
-at 2:09 pm, Peritoneal cleanser in the resident's room in Memory Care Unit.
-at 2:37 pm, stained/soiled carpet flooring in resident's room on the 3rd floor.
-at 2:40 pm, resident (R3) has medications in the bathroom. R3's LIC602A indicated dementia. LPA verified, and per Wellness Director, R3 is on facility's Medication Program.
-at 2:57 pm, cleaning supplies in unlocked housekeeping room on the 5th floor.
-at 3:05 pm, stained/soiled carpet flooring in resident's room on the 5th floor.
-at 4:45 pm, staff (S3) does not have the 20 total hours of required training for 2023.
-at 5:20, staff (S1 and S5) has not completed the required 40 hours of training. S5 has not completed the required total initial hours of medication training.
-at 6:00 pm, residents (R2 and R4) has postural support (halo; half bed rails) but no doctor's orders on file.

The following updated/current documents to be submitted by October 10, 2024:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiencies and plan and proof of corrections were discuss with AED.

Due to time constraint, LPA will come back to continue inspection.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penaly Assessment, LIC9098 Proof of Correction form 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: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2024 08:53 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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 as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which poses an immediate s afety or personal rights risks to persons in care: razor, hair developer, perming agent, waving lotion, anti fungal wash and screw driver in unlocked drawers in unlocked salon; cleaning supplies in unlocked housekeeping room on the 5th floor. This is a repeat violation within 12-month period. A citation was issued on 10/04/23.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	AED locked the salon and the housekeeping room. In addition, an in-service will be conducted and proof to be submitted by 9/27/24.

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in R3 having medications in the room and Peritoneal cleanser in another resident's room which poses an immediate health, safety and/or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Peritoneal cleanser was removed. AED stated she'll have the medications locked. In addition, an in-service to be conducted and proof to be submitted by 9/27/24.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2024 08:53 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in stained/soiled carpet flooring which pose a potential health and/or personal rights risks to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	AED stated she'll have the carpet cleaned. Pictures to be submitted by 10/10/24.

Type B

Section Cited

HSC

1569.69(a)(1)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S5 not having the require total initial hours of medication training which poses a potential health and/or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Staff to complete the required medication training and submit proof by 10/10/24.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/26/2024 08:53 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.625

§1569.625 Staff training; legislative findings; contents (b)(1)…training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required..... before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment….(2) ... training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in S1, S3 and S5 not completing the required numbers of hours of training which poses a potential health, safety or personal rights risks to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	AED to have the staff complete the training and submit proof by 10/10/24.

Type B

Section Cited

CCR

87608(a)(b)

87608 Postural Support (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in R2 and R4 not having doctor’s order for the postural support which pose a potential safety and/or personal rights risks to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Doctor's orders to be obtained and copies to be submitted by 10/10/24.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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