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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 12/15/2020
Date Signed: 12/15/2020 04:38:32 PM

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:ROSANA FRIASFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: 55DATE:
12/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH: Rosana Frias/Associate Executive DirectorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Delmundo conducted a case management with Associate Executive Director Rosana Frias. LPA informed Ms. Frias that the purpose of the case management is regarding the incident reports for residents (R1 and R2) received by LPA on this day, December 15, 2020. Due to Shelter in Place Order and management directive to telework, this case management is conducted via tele conference.

Report indicated the following:
1. Resident (R1)
On December 12, 2020, R1 was found not in his room when staff brought him lunch. Staff searched the dining room and common areas but unable to find him. Staff reported to Wellness Director (WD). Further search done but unsuccessful. Responsible person, executive director and associate director were informed. WD was about to call the police when R1 returned with police escort.
2. Resident (R2)
On December 10, 2020, R2 was found on the floor in her right side lying position with moderate nose bleeding and right eye swollen and red. Staff called 9-1-1 and R2 was brought to the hospital. R2 was admitted for further evaluation.

On this same day, December 15th, LPA conducted interview.

LPA requested Ms. Frias to submit the following by tomorrow, December 16th: LIC601 Identification and Emergency Notification; Physician's Report; Pre-placement Appraisal; Appraisal/.Needs and Services Plan; staff schedule

Exit interview conducted and copy of this report provided to Ms. Frias via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020
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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