<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 03/08/2025
Date Signed: 03/08/2025 03:05:35 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
09/01/2021 and conducted by Evaluator Bennett Fong
COMPLAINT CONTROL NUMBER: 15-AS-20210901144412
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:170CENSUS: DATE:
03/08/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Henrietta BesharesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Facility staff did not administer medication to resident according to physician's instructions.
-Resident sustained fall(s) resulting to injuries due to lack of supervision.
-Staff did not safeguard resident's personal belongings.
-Facility staff did not notify the resident's authorized representative of resident's injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/8/25 at (time) LPM Jeremy Fong arrived unannounced to deliver the findings for the above allegations. LPM met with Community Relations Director, Henrietta Beshares, and informed her of the purpose of visit.

During the course of investigation, the following resident’s documents were obtained: medical records; admission agreement; LIC601 Identification and Emergency Information; LIC602A Physician's Report; Pre-placement Appraisal; Reappraisals (2019, 2020 and 2021); LIC621 Client/Resident Personal Property and Valuables; LIC622 Centrally Stored Medication and Destruction Record; Medication Administration Records; incident reports (2019, 2020 and 2021). The Department also obtained copies of resident roster and staff schedule. Family member (FM), staff, medical providers (PCP, MD1 and MD2) and residents were interviewed on 10/2021, 12/2021, 1/19/2022, 8/2022 and 1/2023. Medical records and facility Call Button Log were reviewed.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Pam Gill
LICENSING EVALUATOR NAME: Bennett Fong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20210901144412
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: 03/08/2025
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
26
27
28
29
30
31
32
Allegation: Facility staff did not administer medication to resident according to physician's instructions. Unsubstantiated.

It was alleged that facility staff did not administer medication to resident (R1) according to physician's instructions. Reporting party (RP) stated R1 was admitted to the facility on 2016, and from 2016 to 2019, R1 was administered insulin. It was further alleged that the Humalog injection was discontinued on 2019, and facility retained R1 that the facility could no longer care for as R1 has diabetes and needs insulin. These dates are all prior to the current License for this facility issued on 10/09/2020.

R1’s family member (FM) was interviewed who stated R1 was admitted to the facility 2016 and had (Humalog) insulin medication which facility discontinued to administer July 2019. FM received a bill in October 2019 that did not include R1’s insulin medications. FM indicated that staff S1 (facility’s registered nurse) told FM that as of October 2019, staff stopped giving R1 insulin injections. Review of records showed the facility sent request to R1’s primary care physician (PCP) to discontinue the Humalog sliding scale as Casa Sandoval scope of service does not allow the use of sliding scale insulin since non-clinical caregivers are assisting with the injections. PCP ordered Humalog sliding scale to be discontinued on July 24, 2019. When R1 was seen by PCP the After Visit Summary dated November 5, 2019 showed medications that were ordered to be continued included Humalog and Novolog. PCP indicated during interview on January 6, 2022 that during R1’s visit on November 5, 2019, R1 was still to be on insulin injections and nothing was changed with the dosages. However, it was not established that this information had been conveyed to the current Licensee.

Hospice care was ordered for R1 and was started on November 22, 2019. Some medications were discontinued (dc’d) by hospice doctor (MD1), and while MD1 stated during interview that all medications would have been discontinued when the resident was placed on hospice, MD1’s list didn’t include Humalog and Novolog to be discontinued. November 2019 Medication Administration Record showed Humalog was not administered from 11/05/19 to 11/22/19, and Novolog was discontinued on November 22, 2019. R1 was discharged from hospice care June 20, 2020. These actions took place prior to the current License. Further, the PCP stated having had no knowledge of the resident being placed on hospice and changes made to the resident’s medication regimen.
SUPERVISORS NAME: Pam Gill
LICENSING EVALUATOR NAME: Bennett Fong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 15-AS-20210901144412
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: 03/08/2025
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
26
27
28
29
30
31
32
Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and it could not be established that the current Licensee was made firmly aware that diabetic medications were to be continued and/or restarted. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore the allegation is Unsubstantiated.

Allegation: Resident sustained fall(s) resulting to in injuries due to lack of supervision. Unsubstantiated.

A review of the call button log from 6/1/2021 to 7/31/2021 showed 127 safety check-ins staff conducted on R1. R1 never pressed the emergency button to request staff assistance. None of the facility staff were aware R1 had sustained a fracture as R1 never complained of any pain, other than back pain from sitting in the recliner too long. Staff found out about the fracture when R1’s son, FM, reported it to the facility after R1’s hospitalization. During FM’s interview, FM stated R1 initially denied falling but later recalled she had and did not tell staff. A review of Hospital Discharge Summary stated R1 sustained a left femoral fracture from a fall. Orthopedist (MD2) confirmed R1’s fracture was due to a fall but was unable to tell whether the fracture was old or new. The Department interviewed R1 but R1 was unable to provide information.

Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and determined that it could not be proven that R1s injuries were recent or new, nor that they were the result of insufficient care and supervision. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated.

Allegation: Staff did not safeguard resident's personal belongings. Unsubstantiated.

It was alleged that staff and other residents were taking R1 personal belongings such soda in R1 refrigerator and other items.
SUPERVISORS NAME: Pam Gill
LICENSING EVALUATOR NAME: Bennett Fong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210901144412
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: 03/08/2025
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
26
27
28
29
30
31
32
Staff (S1 and S2) were interviewed on 1/31/23 and 1/20/23. S1 stated she was not aware that R1 had soda in R1’s refrigerator. R1 was given Ensure and Ensure is labelled with resident’s name, and kept in medication cart. S2 indicated she never heard nor has anyone reported to her that R1's soda or other items are missing. It was never communicated to her by FM that R1's soda and other items were missing; otherwise, S2 will be involved and will the communicate with the staff. Missing items were never reported to them.

Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and could not determine the factual accuracy that personal items had gone missing. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated.

Allegation: Facility staff did not notify the resident's authorized representative of resident's injuries. Unsubstantiated.

The Department interviewed FM and staff. During FM’s interview, FM stated R1 initially denied falling but later recalled she had and did not tell staff. R1 was interviewed and stated her leg problem was due to old age. Staff (S1, S3, S4, S5, S6, S7, S8 and S8) were interviewed on 12/08/21, 12/16/21, 12/30/21. These staff stated R1 didn’t complain of pain, not being aware that R1 had fallen and sustained fall. S1 stated she was not aware R1 had fallen and sustained a fracture. S1 indicated she came to know after R1 was hospitalized.

Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and could not establish that facility staff had been aware of, and/or, informed that R1 had sustained a fall prior to going to hospital, nor whether the fracture found was recent or old. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Pam Gill
LICENSING EVALUATOR NAME: Bennett Fong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4