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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 10/22/2025
Date Signed: 10/22/2025 12:04:57 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
10/20/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20251020151658
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: 26DATE:
10/22/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Seema Sandhu, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility did not give refund to Resident's responsible party
INVESTIGATION FINDINGS:
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On 10/22/25 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, gathered information and delivered investigation finding to administrator (ADM). LPA explained the purpose of the visit with ADM.

During investigation, LPA interviewed reporting party(RP/POA), facility staff (ADM, S1) and obtained the following documents from administrator: Personnel record (LIC500), Resident roster (LIC9020), Resident’s (R1) admission agreement, Physician’s report, Needs & Services plan, death report.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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 3
Control Number 15-AS-20251020151658
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: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
VISIT DATE: 10/22/2025
NARRATIVE
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Allegation: Facility did not give refund to resident’s responsible party
Finding: Substantiated
During investigation, LPA interviewed reporting party (RP), facility staff (ADM, S1) and reviewed former resident’s (R1) documents. Review of R1’s admission agreement and death report showed he was first admitted at the facility on 10/30/2020 and expired on 03/09/25. RP stated she sent several text messages to ADM and a priority letter with tracking to the facility requesting for a refund on 06/10/25 with no response. RP also stated she donated all of R1’s belongings to the other residents when he passed away on 03/09/25. On 10/22/25 at 11:15 AM, ADM spoke with RP on the phone and both agreed to a final refund amount of $3,477.46. LPA observed ADM mail the refund check to RP during visit. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that facility did not give refund to resident’s responsible party is substantiated.

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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20251020151658
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: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2025
Section Cited
HSC
1569.652(c)
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A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed…
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Defiiciency corrected during visit. ADM issued refund check to POA on 10/22/25.
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This requirement was not met as evidenced by facility not giving the refund to resident’s responsible party which posed a potential health & safety risk to resident 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: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3