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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 08/12/2021
Date Signed: 08/12/2021 02:39:09 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:APOLINARIO C. GOZONFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: 52DATE:
08/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Apolinario 'Paul' Gozon/Executive DirectorTIME COMPLETED:
01:15 PM
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While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo discussed with Executive Director Apolinario 'Paul' Gozon the following:
1. Conditional use permit for the application for increase in capacity from 99 to 170 (assisted = 130; memory care = 40). Paul Gozon indicated he will follow-up with Associate Planner Development Services before the end of this week and will update LPA.
2. Construction/upgrade - LPA conducted a quick tour of the first and second floors with Paul Gozon. When verified, he stated there are no alterations on the physical plant and all work which LPA observed on-ongoing are all upgrades.
3. Delayed egress - to be installed on the second floor.
4. Application for increase capacity process
5. Fire Safety Inspection Request

LPA to review the second floor sketch submitted by Paul Gozon on August 10, 2021. Once review is completed, LPA to submit the sketches and STD850 Request for Fire Safety Inspection to the fire department.

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: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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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