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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201172
Report Date: 07/01/2025
Date Signed: 07/01/2025 01:25:05 PM

Document Has Been Signed on 07/01/2025 01:25 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FRIENDSHIP CARE HOMEFACILITY NUMBER:
079201172
ADMINISTRATOR/
DIRECTOR:		SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 35CENSUS: 31DATE:
07/01/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Facility Manager/Nurse, Cindy MurphyTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 7/1/25 at 9:00AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of observations made during a facility visit on 6/11/2025. LPA met with Facility Manager/Nurse, Cindy Murphy and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, common areas, and out door patios.
THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • PUB 475 Poster is not the correct dimensions 87468(c)(2)(A)
  • Facility is placing residents in walkways to eat meals because dining area can not accommodate all residents. 87307(a)(1)
  • R1 and R2 are both utilizing chairs with attached lap trays however there is not an exception or doctors orders for the postural supports 87608(a)
  • LPA observed expired Almond milk for the residents being used in the kitchen 87555(b)(8)
  • LPA observed the floors in the kitchen/food area sticky and dirty with debris and food 87303(a)(1)
  • LPA observed that food is not properly stored in the kitchen. 87555(b)(9)
  • LPA observed that the MAR is incomplete for all residents. 87465(d)
  • LPA observed the file incomplete for R1 87506(b)
  • LPA observed R1 asking S1 to go outside and S1 telling them they would have to go later. When LPA asked why S1 stated because there were not enough staff to supervise them outside. 87411(a)
  • LPA observed unlocked scissors at the front desk accessible to residents.87309(a)***
  • Facility is not developing and following a weekly menu 87555(b)(6)

***Civil Penalty issued in the amount of $250 for repeat violation***

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.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/01/2025 01:25 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/01/2025 at 09:46 AM
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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2025
Section Cited
CCR
87468(c)(2)(A)

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(c)Licensees shall prominently post(2)Information...shall be posted as follows:(A) Licensees may use...PUB 475. The poster that is posted shall be 20" x 26" in size...

This requirement is not met as evidence by:
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By POC facility agrees to obtain the PUB 475 with the correct dimensions and notify CCLD.
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Based on observation the facility did not comply with the section above by PUB 475 poster being the incorrect dimensions and too small which poses a potential personal rights violation for residents in care.
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Type B
07/17/2025
Section Cited
CCR87307(a)(1)

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(a) Living...shall be large enough...The following provisions shall apply:(1) There shall be...dining rooms...shall be of sufficient...from interfering with other functions.

This requirement is not met as evidence by:
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By POC Facility agrees to develop a plan for meal times where clients are not placed in walkways and notify CCLD
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Based on observation the facility did not comply with the section above by placing residents in the walkways to eat because the dining area is insufficient which poses a potential personal rights violation for 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 01:25 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/01/2025 at 12:32 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2025
Section Cited
CCR
87608(a)

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(a) Based on the individual's preadmission appraisal...Postural supports may be used under the following conditions

This Requirement is not met as evidence by:
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By POC facility agrees to obtain new 602s and physcians orders for all residents utilizing postural supports.
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Based on observation and file review the facility did not comply with the section above by R1 and R2 utilizing postural supports that are not documented in their file and do not have spring releases which pose an immediate personal rights violation for residents in care.
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Type A
07/01/2025
Section Cited
CCR87309(a)

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(a) Except as specified.. sharp objects, and other similar items..are in locked storage ...

This Requirement is not met as evidence by:
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Facility locked away scissors POC Clear.
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Based on observation the facility did not comply with the section above by having unlocked and accessible scissors which pose an immediate personal rights violation safety risk for 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 01:25 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/01/2025 at 12:42 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2025
Section Cited
CCR
8755(b)(8)

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(b) The following..shall apply:(8) All food shall be of good quality...

This requirement is not met as evidence by:
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By POC facility agrees to audit and dispose of all expired foods and notify CCLD
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Based on observation the facility did not comply with the section above having expired food which poses a potential health and personal rights violation for residents in care.
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Type B
07/17/2025
Section Cited
CCR8755(b)(9)

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(b) The following..shall apply:(9)Procedures.. of food shall be observed in food storage...

This requirement is not met as evidence by:
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By POC facility agrees to conduct an inservice with kitchen staff and purchase food storage containers and notify CCLD
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Based on observation the facility did not comply with the section above by not storing food properly which poses a potential health violation for 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 01:25 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/01/2025 at 12:48 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2025
Section Cited
CCR
87555(b)(6)

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(b) The following..shall apply:(6)In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance...

This requirement i not met as evidence by:
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By POC facility agrees to create and impliment a weekly menu and document the dishes when served and also provide kitchen staff with training on nutrition and notify CCLD
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Based on observation the facility did not comply with the section above by not creating and following a weekly menu which poses a potential personal rights violation for residents in care.
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Type B
07/17/2025
Section Cited
CCR87303(a)(1)

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(a) The facility shall be clean...(1) Floor surfaces in ... kitchen areas...

This requirement i not met as evidence by:
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By POC facility agrees to clean the kitchen and kitchen floors and notify CCLD
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Based on observation the facility did not comply with the section above by kitchen floors being dirty which poses a potential health risk for 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/01/2025 01:25 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/01/2025 at 12:58 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2025
Section Cited
CCR
87465(d)

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(d)If the resident is unable to determine...all of the following requirements are met:

This requirement is not met as evidence by:
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By POC Facility agrees to update and maintain the MAR as well as provide additional training to staff and notify CCLD.
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Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.
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Type B
07/17/2025
Section Cited
CCR87506(b)

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(b) Each resident’s record shall contain at least the following information:


This requirement is not met as evidence by:

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By POC facility agrees to review all resident records and update them as necessary and notify CCLD
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Based on record review the facility did not comply with the section above by having incomplete resident records which poses a potential personal rights violation for 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 01:25 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/01/2025 at 01:09 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2025
Section Cited
CCR
87411(a)

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(a)Facility personnel shall at all times be sufficient in numbers... to meet resident needs...

This requirement is not met as evidence by:
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By POC facility agrees to hire an additional caregiver for each shift and notify CCLD.
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Based on observation and conversation the facility did not comply with the section above by not having a sufficient number of staff to meet the residents needs which poses a potetional personal rights violation for 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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