019200922-1-16-2025-15-AS-BFOG-DE8U79-20250225141934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 01/16/2025
Date Signed: 01/16/2025 07:23:35 PM

Unsubstantiated

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
03/19/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240319155109

FACILITY NAME:	CASA SANDOVAL		FACILITY NUMBER:	019200922
ADMINISTRATOR:	HENRY, CAYIA		FACILITY TYPE:	740
ADDRESS:	1200 RUSSELL WAY		TELEPHONE:	(510) 727-1700
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	170	CENSUS: 104	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Associate Executive Director Rosana Frias		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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-Facility failed to seek medical attention for resident (R1) in timely manner.

-Facility improperly assisted resident (R1) with medical needs.

-Staff not responding to responsible person's request for communication regarding resident's (R1) care and services.

-Staff interfere with residents' mail.

INVESTIGATION FINDINGS:

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On this day, 1/16/25, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Associate Executive Director (AED) Rosana Frias. and informed the reason for visit.

During the course of investigation, LPA obtained copies of staff schedule and resident roster. LPA obtained copies of including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Reports; doctor's orders of medications; Medication Administration Records (MAR); LIC622 Centrally Stored Medication and Destruction Records; doctor's orders of medicaitons; facility notes; blood pressure log; facility's records of communication with Pine Park Health and R1's responsible person (FM). LPA interviewed staff (former ED, AED, S1, S2, S3, S4, S5, S6, S7) on 3/22/24 and 1/16/25, obtained information from FM on 5/22/24, interviewed residents (R2, R3) on 1/16/25 and obtained information from Pine Park Health staff (PP1).
....continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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 4

Control Number 15-AS-20240319155109

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: 01/16/2025

NARRATIVE

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Page 2

Allegation: Facility failed to seek medical attention for resident (R1) in timely manner.
Reporting party (RP) stated that R1 has doctor's order to monitor blood pressure (BP) and was prescribed medication back in 2022. RP further stated that on 2/19/24, Pine Park Nurse Practitioner (W1) called R1's responsible person (FM) and told FM that R1 will be sent out due to the BP being out of control. RP alleged that facility did not call 9-1-1.

LPA reached out to W1 but W1 did not return LPA's call. PP1 confirmed W1 has an order sent to the facility to check R1's blood pressure from 2/07/24 to 2/14/24. Review on Unusual Incident Report showed staff (S1) called 9-1-1 on 2/19/24 and that W1 was notified and that FM was aware. LPA interviewed S1 who confirmed she called 9-1-1 and that R1 was sent out due to high blood pressure.

Based on information gathered and LPA unable to obtain information from W1, and LPA not able to interview R1 due to R1's medical diagnosis of R1, the allegation is unsubstantiated.

Allegation: Facility improperly assisted resident (R1) with medical needs.
It was alleged that R1's urine sample was sent by the facility to a different laboratory other than Pine Park Health.

Review of record showed order for urinalysis. Review of facility notes, communication with Pine Park Health and FM showed that FM was informed about the urine sample. LPA interviewed the Wellness Director and S1 who stated that Pine Park has third party, Labcorp and GTI, that picks-up the urine sample. LPA tried to reach W1 but W1 did not return LPA's call. Therefore, the allegation is unsubstantiated.

...continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20240319155109

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: 01/16/2025

NARRATIVE

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Allegation: Staff not responding to responsible person's request for communication regarding resident's (R1) care and services.
RP stated that staff S2 opened R1's mail and that FM wants to know what's going on and requested to have a meeting/discussion with former Executive Director (ED). The ED told FM she will look on it. FM had a phone conversation on January 6, 2024 regarding the issues and concerns FM brought up but never got a response/answer from former ED.

LPA interviewed former ED who stated she talked to FM a lot over the phone, one was on 11/28/23 for 39 minutes, on 12/20/23 for 15 minutes, and for 16 & 20 minutes on 1/03/24. S1 also provided FM updates via phone calls and text messages. Copies of text messages, proof of phone calls obtained by LPA confirmed former ED's statements. LPA interviewed S1 who stated she communicated and provided updates to FM. S2 stated she communicated with FM via email, text & phone calls and has got into a point where FM communicated and called the staff daily. S1 also stated that they set up a weekly schedule which FM agreed, and assigned S1 and she (S2) will step up if S1 is not available to speak with FM. S2 stated that iff S1 is not available, FM will S2, the former ED and that FM also calls outside the weekly schedule.

Based on information obtained, the allegation is unsubstantiated.

Allegation: Staff interfere with residents' mail.
It was alleged that R1's mail was opened by staff.

S2 stated when she went to R1's apartment on 12/2023 to check on R1, she observed a correspondence pertaining to insurance which need to be renewed by 01/2024, so she sent the picture of the correspondence to FM which LPA obtained a copy of the text message and correspondense. S1 denied opening R1 or any of residents' mail and stated she does not have key to R1's mailbox. LPA interviewed other staff (S1, S2, S3, S4, S5, S6 and S7) who all denied opening residents' mail. AED stated not observing staff opening residents mail nor was brought to her attention. LPA also interview residents (R2 and R3) who stated their mail were never opened by staff. Therefore, the allegation is unsubstantiated.

......continued on 9099C (page 4)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20240319155109

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: 01/16/2025

NARRATIVE

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Page 4

Based on interviews, records review, and LPA unable to obtain information from W1 and R1, the 4 allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the 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: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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