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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 12/22/2023
Date Signed: 12/22/2023 05:07:52 PM

Document Has Been Signed on 12/22/2023 05:07 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: 170CENSUS: 69DATE:
12/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Cayia Henry/Executive DirectorTIME COMPLETED:
05:10 PM
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On this day, 12/22/23, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 10/04/23. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit.

LPA reviewed 5 residents records. LPA checked the medications and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2023
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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