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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 09/06/2021
Date Signed: 09/06/2021 04:26:18 PM

Document Has Been Signed on 09/06/2021 04:26 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 SANDOVALFACILITY NUMBER:
019200922
ADMINISTRATOR:APOLINARIO C. GOZONFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 99CENSUS: 53DATE:
09/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20210901144412). LPA met with Assisted Living Coordinator Vivian Valeros and informed the purpose of visit. Vivian called Associate Executive Director Rosana Frias who arrived after twenty (25) minutes.

LPA started the inspection with Vivian Valeros and Activity Director Ricky Dulay and continued with Rosana Frias. LPA inspected the common areas on the ground floor, kitchen, dining room and patio. LPA randomly selected for inspection 4 resident rooms on the second floor and 4 resident rooms on the third floor.

LPA observed the following:
1. Patio - snail and slugs killer and garden bugs killer spray; uneven pavement by the dining room exit door; pieces of construction metal
2. Second floor - frayed carpet flooring by entrance door in one of the resident's rooms.
3. Third floor - bathroom doors in one of the resident's rooms.

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

Deficiencies and plan and proof of corrections were discussed with Rosana Frias.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/06/2021 04:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/06/2021 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA SANDOVAL
FACILITY NUMBER: 019200922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2021
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Associate Executive Director (AED) had the insect killers locked and the bathroom doors removed from the bedroom immediately.

AED to have following done:
1. Have the carpet flooring fixed/repaired.
2. Fix the uneven pavement.
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-Based on observation, the licensee did not comply with the section cited above. LPA observed the following which pose immediate health and safety risks to persons in care: frayed carper flooring in resident's room; bathroom doors in one of resident's bedroom; insect killers, uneven pavement and pieces of metal in the patio
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3. Remove the pieces of metal from the patio and/or place a yellow construction tape around the area.
4. In-service the staff.
Pictures and copy of in-service training to be submitted by 9/07/2021.

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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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2021


LIC809 (FAS) - (06/04)
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