<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201172
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:45:52 PM

Document Has Been Signed on 06/16/2022 03:45 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:FRIENDSHIP CARE HOMEFACILITY NUMBER:
079201172
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 35CENSUS: 30DATE:
06/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/16/22 at 3:30PM, while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio discussed that there was no unusual incident report (LIC 624) submitted on 06/03/22 to CCLD reporting there were 4 COVID positive residents on that day.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/16/2022 03:45 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 06/16/2022 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
87211(a)(2)

1
2
3
4
5
6
7
Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate
1
2
3
4
5
6
7
By POC due date, administrator agrees to submit to CCLD self certification that staff has read and will comply with Title 22 Section 87211 reporting requirements.
8
9
10
11
12
13
14
This requirement was not met as evidenced by absence of LIC 624 on incident which posed a potential health & safety risk to residents in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2