019200922-10-4-2023-15-AS-ADEO-CWB55W-20231004193950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 10/04/2023
Date Signed: 10/04/2023 07:40:01 PM

Document Has Been Signed on 10/04/2023 07:40 PM - It Cannot Be Edited

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 SANDOVAL		FACILITY NUMBER:	019200922
ADMINISTRATOR:	APOLINARIO C. GOZON		FACILITY TYPE:	740
ADDRESS:	1200 RUSSELL WAY		TELEPHONE:	(510) 727-1700
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	170	CENSUS: 64	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Cayia Henry/Executive Director		TIME COMPLETED:	07:45 PM

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	Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Executive Director (ED) Cayia Henry, and informed the purpose of visit. Facility is a seven story building, 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has an LIC808 Mitigation Plan on file; however, Infection Control Plan on facility file was dated January 2020, and needs updating. LPA inspected the facility inside and out with ED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies room on other floors and laundry room were checked and observed locked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept. LPA observed the freezer and refrigerator temperatures were at -7.0 and 35 degrees Fahrenheit respectively. LPA randomly selected 8 residents rooms for inspection - 2 each on 2nd, 3rd, 4th and 5th floors. Facility has carbon monoxide and smoke detectors and observed functional. Hot water temperature in one of the resident rooms on the 2nd floor was tested and measured at 116.8 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced August 28, 2023. Facility has evacuation chairs on stairwells. Facility conducts disaster drills for all shifts every quarter. and records showed last conducted September 26. 2023. LPA reviewed 5 staff files, and interviewed 4 staff and 4 residents. .......continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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
	VISIT DATE: 10/04/2023

NARRATIVE

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LPA observed the following:
-at 12;05 pm, blade and scissors in the drawer without lock in unlocked salon.
-at 12:10 pm, professional strength glue, scissors, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room.
-staff (S2) does not have First Aid certificate.
-staff (S5) does not have the required 8 hours of medication training for 2022.

The following updated/current documents to be submitted by October 18, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Infection Control Plan and Monkeypox Infection Control Plan

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiencies and plan and proof of corrections were discuss with ED.

Due to time constraint, LPA will come back to continue inspection.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2023 07:40 PM - It Cannot Be Edited

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: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for blade and scissors in the drawer without lock in unlocked salon, and professional strength glue, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room. These pose an immediate health and/or safety risks to persons in care. This is a repeat violation within 12 months period. First citation was issued on 8/03/23. A $250.00 civil penalty is assessed.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	ED locked the rooms. In addition, ED to conduct in-service training and submit copy of training topic with attendees signatures by 10/05/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/04/2023 07:40 PM - It Cannot Be Edited

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: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for staff (S2) not having first aid training and/or certificate on file which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	ED to have the staff trained and submit proof by 10/18/23.

Type B

Section Cited

HSC

1569.69

§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for staff (S5) not having the required 8 hours of medication training for 2022 which poses a potential health risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	ED to have the staff complete the required training and submit proof by 10/18/23,

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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