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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 09/03/2021
Date Signed: 09/03/2021 01:10:04 PM



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
05/03/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210503093311
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: 53DATE:
09/03/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Facility is not ensuring resident (R1) receives sufficient meal.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation. LPA met with Associate Executive Director Rosana Frias and informed the purpose of LPA's visit.

On May 10, 2021, LPA obtained R1's following documents: LIC601 Identification and Emergency Information; Physician's Report; Appraisal/Needs and Services Plan; notification of initiation of hospice care; hospice pre-admission assessment; hospice visit notes; death report.

LPA interviewed staff (S1, S2, S3 and S4), R1's family members (FM1 and FM2) and hospice nurse (H1). Staff indicated that prior to being placed on hospice care, R1 was independent on eating/feeding. R1 was assisted in feeding when R1 was placed on hospice care. R1 eventually refused to eat as she declined. Staff's statements collaborated with information obtained from FM1 and FM2 who also indicated they never had problem with the facility. H1 indicated that R1's medical condition could have contributed to the way R1 ate.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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 2
Control Number 15-AS-20210503093311
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: 09/03/2021
NARRATIVE
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Based on all information obtained, the allegation of "facility is not ensuring resident receives sufficient meal" is closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore the complaint is dismissed.

Exit interview conducted and copy of this report provided to Rosana Frias.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2