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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201172
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:42:25 PM

Document Has Been Signed on 10/07/2022 04:42 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: 34DATE:
10/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Esmeralda Vega, SupervisorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 10/07/2022 at 11:40 am, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen conducted a Case Management while at the facility for complaint (CN# 15-AS-20220930151105 and CN# 15-AS-20220929165630). LPAs met with Supervisor, Esmeralda Vega and explained the purpose of the visit. LPAs spoke to Administrator over the phone and Administrator is not available.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
  • At 11:40 AM, LPAs observed ottoman blocking an exit door. There are 3 beds and wheel chairs obstructing another exit door.
  • At 3:20 PM during record review, R1 was admitted to the hospital for spitting out blood. However, an incident report was not submitted CCLD. S1 confirmed an incident report was not submitted.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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 10/07/2022 04:42 PM - It Cannot Be Edited


Created By: Lizette Francisco On 10/07/2022 at 03:43 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: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited
CCR
87307(d)(6)

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87307(d)(6) PERSONAL ACCOMODATIONS AND SERVICES
(d)The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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By POC date, Administrator will remove items and submit a photo to CCLD.
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This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above by storing items blocking the exit doors which poses a potential health and safety risk to persons in care.
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Type B
10/14/2022
Section Cited
CCR87211(a)(1)

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87211(a)(1) REPORTING REQUIREMENTS
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...

This requirement is not met as evidenced by:
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By POC date, Administrator will review regulation and submit a self-certification letter (LIC 9098) to CCLD
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Based on record review, Licensee did not comply with the regulation cited above by not submitted an incident report for R1 which poses a potential heatlh and safety risk to residents 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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