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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 09/26/2024
Date Signed: 09/26/2024 09:02:13 PM

Substantiated


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
01/17/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230117150311
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: 105DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
08:15 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
09:15 PM
ALLEGATION(S):
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Facility failed to supervise resident (R1) resulting to intoxication.
INVESTIGATION FINDINGS:
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On this day, September 26, 2024, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias, and informed of the reason for visit.

It was alleged that resident (R1) was seen at the hospital on 1/14/2023 after an unwitnessed fall. The doctor noted, "fall occurred in setting of alcohol intoxication”.

During investigation, LPA obtained copies of resident roster and staff schedule, and conducted interviews. LPA also obtained copies of R1’s following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician’s Report; facility notes; Hospital Discharge Summary; Letter of Conservatorship; email from conservator; Alcohol Intake Record; Unusual Incident Report (UIR).

...continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 5
Control Number 15-AS-20230117150311
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: 09/26/2024
NARRATIVE
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UIR indicated that at 1:30 am on 1/14/23, R1 was found on the floor of his room, was breathing but unable to be awaken. 9-1-1 was called and R1 was transported to the hospital. Hospital Discharge Summary showed diagnosis of alcohol intoxication among others with alcohol level of 244 on arrival, and that R1 stated he drinks ‘too much’ Vodka.

On 1/19/23, LPA interviewed staff (S1 and S2) and R1’s current conservator (C1). S2 confirmed the incident happened on 1/14/23. S1 stated R1 is allowed 1 drink of travel size of Vodka of about 2 oz/day, but it doesn’t mean R1 will not ask for more and if not given, R1 will become belligerent. C1 stated that when he visited R1 one morning, C1 observed a stain in the carpet in R1’s room on which the staff stated that it’s alcohol. Review of records showed R1’s former conservator (C2) gave permission to the facility to purchase Vodka, not to give all at once and only let R1 consume 1 small bottle at night only. Facility's Alcohol Intake Records for R1 showed R1 was given from 2 to 3 times in the evening of which each time R1 was given 2 to 4 cups of 5 oz/cup. Records also showed there were days when R1 was given 5 oz at 1:00 am, 1:20 am, 1:30 am, 2:30 am and on those days, R1 was also given at night.

Based on information gathered, the preponderance of evidence is met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.



Deficiency and plan and proof of correction were discussed with the AED.

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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230117150311
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
1569.269(a)(16)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (16) To reasonable accommodation of individual needs and preferences in all aspects of life in the facility, except when the health
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R1 is no longer at the facility.

Executive Director to in-service the staff and submit proof by 10/10/24.
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or safety of the individual or other residents would be endangered.
-This requirement is not met as evidenced by:
-Based on interviews and records review, the licensee did not comply with the section above in giving the resident alcohol more that the permitted amount.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/17/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230117150311

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: 105DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
08:15 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
09:15 PM
ALLEGATION(S):
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Staff did not assist resident (R1) with hydration.
INVESTIGATION FINDINGS:
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On this day, September 26, 2024, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias, and informed of the reason for visit.

It was alleged that resident (R1) was seen at the hospital on 1/14/2023 after an unwitnessed fall. The doctor noted, "dehydration”.

During investigation, obtained copies of resident roster and current staff schedule, and conducted interviews. LPA also obtained copies of R1’s following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician’s Report; facility notes; Hospital Discharge Summary; Letter of Conservatorship; email from conservator; Alcohol Intake Record; Unusual Incident Report (UIR).

....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230117150311
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: 09/26/2024
NARRATIVE
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UIR indicated that at 1:30 am on 1/14/23, R1 was found on the floor of his room, was breathing but unable to be awaken. 9-1-1 was called and R1 was transported to the hospital.

On 1/19/23, LPA interviewed staff (S2) who confirmed the incident that happened on 1/14/23. Review of LIC602A Physician’s Report revealed R1 does not need assistance with feeding. LPA was unable to interview R1.

Based on all information obtained and due to LPA was not able to obtain information from R1, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.



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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5