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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 12/05/2024
Date Signed: 12/05/2024 06:13:23 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
02/22/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240222115320
FACILITY NAME:CASA SANDOVALFACILITY NUMBER:
019200922
ADMINISTRATOR:HENRY, CAYIAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 105DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Non-medical staff members administering injections.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and deliver the findings for the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit.

During the course of investigation, LPA obtained copies of resident roster and staff schedule. LPA reviewed residents records and obtained copies of LIC602A Physician Report.

LPA interviewed 5 residents (R1, R2, R3, R4, R5) on 2/29/24. Three (3) out of these 5 residents stated the med-tech administers insulin. LPA reviewed 4 residents records which showed 2 of these 4 residents unable to perform their own glucose testing and injections. The other 2 residents are able to perform glucose testing and administer own insulin.

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

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 3
Control Number 15-AS-20240222115320
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: 12/05/2024
NARRATIVE
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LPA interviewed 7 staff. One of these staff stated she does not administer injection; however, when she told the resident that this resident needs to do it herself, this resident told her that the other med-tech does it. One of the med-techs stated she's not a medical professional nor an LVN but she pricks for glucose tests and administers insulin to 3 residents.

Based on interviews and records review, the preponderance of evidence has been 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 may result in civil penalty.

Deficiency and plan and proof of corrections were discuss with 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: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240222115320
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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2024
Section Cited
CCR
87628(a)
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87628 Diabetes : (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through ..
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AED to do the following and submit proof by 12/19/24:
1. Have all residents records reviewed to deternine who need assistance with injections and have the LVNs perform the injections.
2. Ensure there's LVN scheduled to work
during the time injections are to be performed
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..injection, or has it administered by an appropriately skilled professional.
-This requirement is not met as evidenced by:
-Based on records review and interviews, the licensee did not comply with the section above in having non-medical staff administers insulin injection to residents,
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and submit a copy of LIC500 Personnel Report.
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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3