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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 02:53:35 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 - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Apolinario 'Paul' Gozon/Executive DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct another case management as follow-up to the case management conducted on December 15, 2020. LPA requested for copies of LIC601 Identification and Emergency Notification, Physician's Report, Pre-placement Appraisal, Appraisal/.Needs and Services Plan, staff schedule.

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.

Review of resident’s (R1) LIC602A Physician’s Report revealed R1 is confused/disoriented, has wandering and sundowning behaviors and can not leave the facility unassisted.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) by plan of correction due date and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with Apolinario 'Paul' Gozon.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form 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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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: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2021
Section Cited

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87461 Mental Condition: (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander

This requirement is not met as evidenced by
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-Based on records review, the licensee did not comply with the section cited above. R1 was able to leave the facility unnoticed which posed immediate health and safety risks to person 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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