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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:41:28 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
08/01/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230801150316
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: 94DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Naensila 'Nancy' Randhawa/Executive Director TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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-Resident (R1) sustained a fracture while in care.

-Resident (R1) had multiple falls during transfers.

-Staff is not providing appropriate assistance during transfers.
INVESTIGATION FINDINGS:
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On this day, June 4, 2025, at 2:15 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Nansiela 'Nancy' Randhawa, and informed the reason for visit.

During the course of investigation, the Department obtained copies of including but not limited to the following resident’s documents: LIC601 Identification and Emergency Contact Information; Appraisal/Assessment; LIC602A Physician's Report; Unusual Incident Reports (UIRs); facility notes; doctor's notes; medical records. Copies of resident roster and staff schedules were also obtained. The following were interviewed: resident’s (R1) family member (FM1) on 8/15/23; staff (S1, S2, S3, S4) and Associate Executive Director (AED) on 8/21/23; residents (R1, R2, R3, R4) on 8/21/23; resident (R5) on 9/06/23


....continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 5
Control Number 15-AS-20230801150316
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: 06/04/2025
NARRATIVE
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Page 2

Allegation: Resident sustained a fracture while in care.
LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 noted R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Incident report dated 7/26/23 noted that R1 was helped up from bed and was about to walk with walker to the bathroom when R1’s legs gave out and R1 indicated her legs getting weak and were hurting. R1 fell on her knees and facility staff helped R1 sit up. Lift assist was called to help get R1 up, but R1 could not get up after several attempts with the medics. R1 was taken to the hospital. Medical Records reflected that R1 sustained a displaced supracondylar fracture without intercondylar extension of the lower end of her left femur. Based on records review and interviews, the allegation is substantiated.

Allegation: Resident had multiple falls during transfers.
FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers.FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 02/27/2023, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Lift assist had to be called each time in order to get R1 up. Facility staff admitted that R1 would fall “every single day”. All facility staff interviewed stated they did not believe they could provide the level of care R1 required but kept R1 at the facility anyway. In April of 2023, R1 returned from the hospital to the facility confined to a wheelchair, however, the wheelchair did not fit through R1’s bedroom or bathroom door. Two facility staff would have to physically lift R1 out of R1’s wheelchair and into a standing position supported by R1’s walker. Facility staff would then walk behind R1 as she walked into her bedroom and bathroom. R1’s physical condition prevented her from walking at all which caused R1 to fall constantly. Therefore, the allegation is substantiated.

......continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20230801150316
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: 06/04/2025
NARRATIVE
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Page 3

Allegation: Staff is not providing appropriate assistance during transfers.
FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Therefore, the allegation is substantiated.

Based on the Department’s interviews and records review conducted, the preponderance of evidence has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited from Title 22 California Health and Safety Code and Regulations and listed on 9099Ds.

A $1,000.00 civil penalty is assessed for deficiency section 1569.269(a)(6) which is also a repeat violation within 12 month period. Civil penalty for this deficiency will continue for $100.00 per day until corrected. Additional civil penalty may be assessed based on Health and Safety Code 1569.49(f). Failure to submit proof of corrections by plan of correction due dates for the other deficiencies and any repeat violation within 12 month period may result in additional civil penalties.

Deficiencies, civil penalty, and plan and proof of corrections were discussed with the ED.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230801150316
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: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
HSC
1569.269(a)(6)
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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: (6) To care, supervision, and services that meet their individual needs and are delivered by staff..........
-This requirement is not met as evidenced by:
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Executive Director to do the following and submit proof by 6/05/25:
1. Revisit the facility's transfer procedures.
2. In-service the staff

A $1,000.00 civil penalty is assessed.
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-Based on records reviews and interviews, the licensee did not comply with the section above in not meeting R1’s needs of being non-ambulatory by walking R1 to the bathroom causing R1 to fall and sustained injury which posed an immediate health, safety and/or personal rights risks to person in care.
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Type A
06/05/2025
Section Cited
HSC
1569.269(a)(5)
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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:
(5) To be accorded safe, healthful, and comfortable accommodations.......
-This requirement is not met as evidenced by

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Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 6/05/25.
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-Based on records review and interviews, the licensee did not comply with the section above in not safely meeting R1’s needs resulting to R1's constant falls which posed an immediate health, safety and/or personal rights risks to person in care.
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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: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230801150316
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: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
CCR
87564(f)(2)
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87464 Basic Services
(f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.
-This requirement is not met as evidenced by:
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Executive Director to add to inservice training and submit copy of training topic(s) with attendees signatures by 6/05/25.
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-Based on records review and interviews, the licensee did not comply with the section above in not meeting R1’s transferring needs by walking R1 to the bathroom which posed an immediate health, safety and/or personal rights risks to person in care.
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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: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5