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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701427
Report Date: 07/22/2024
Date Signed: 07/23/2024 09:59:46 AM

Document Has Been Signed on 07/23/2024 09:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:A FRIENDLY ELDERLY CAREHOME, LLCFACILITY NUMBER:
392701427
ADMINISTRATOR/
DIRECTOR:		DREQUITO, SHARONFACILITY TYPE:
740
ADDRESS:1539 FRIENDLY STREETTELEPHONE:
(408) 821-5552
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 0DATE:
07/22/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Sharon DrequitoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 07/22/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility Applicants, Sharon Drequito and Anabelen Vallarta, who were briefly interviewed at this time. This LPA also later met other facility staff persons while conducting these interviews.
Current census was 0 residents.
It was learned that this facility will be seeking to accept and retain up to (2) residents under the care of hospice at any given time.
It was learned that this facility will have a program to be able to accept and retain dementia residents at any given time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located near the facility employee hallway office, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located near the garage area, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate for one of the applicants, Sharon Drequito, was observed to have been completed with number 6069174740 that was set to expire on 04/07/2026 and in compliance at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427
VISIT DATE: 07/22/2024
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Medication cabinet, located in the facility employee office area, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located hanging on the kitchen wall, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher, located hanging on the kitchen wall, was observed to have been recently purchased from the local Costco store on 04/06/2024 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

Component III was conducted with the facility Applicant, Sharon Drequito, at this time.

This facility was found to be in compliance at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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