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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701427
Report Date: 11/26/2024
Date Signed: 11/27/2024 08:59:38 AM

Document Has Been Signed on 11/27/2024 08:59 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: 2DATE:
11/26/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Samuel Saahene, Myrna Sibayan and Anabelen VallartaTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Unannounced Post Licensing visit made out to this facility on 11/26/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility caregivers, Samuel Saahene and Myrna Sibayan, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. Anabelen Vallarta arrived later to this facility while this LPA was conducting this post licensing visit.
Current census was 2 residents.
It was learned that this facility currently has (2) residents under the care of hospice at this time.
It was learned that this facility has 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 reviewed to make sure that they were locked and made inaccessible to the residents at this time.
Administrator certificate for 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: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 11/26/2024
NARRATIVE
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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

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated representative at this time.

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

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/27/2024 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/26/2024 at 04:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [2] facility personnel files did not possess a complete and updated health screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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The facility representative stated that all facility personnel will be scheduled for a medical appointment to undergo and complete an updated health screening. A statement of correction, along with a copy of the updated health screening, will be completed and submitted into CCL by the due date.

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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/27/2024 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/26/2024 at 04:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type A
Section Cited
CCR
87412(a)(13)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in [1] out of [2] facility personnel files did not possess any proper fingerprint clearance, and or association, to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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The facility representative stated that all facility personnel will be scheduled for a LiveScan appointment to undergo and complete an updated fingerprint screening. A statement of correction, along with a copy of the updated fingerprint clearance, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/27/2024 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/26/2024 at 04:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the facility medications were prepared in a weekly pill case for 7 days at a time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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The facility representative stated that this facility will no longer pre-pour any medications. A statement of correction, along with proof of facility in-service for no less than (1) hour in duration, on the topic of no longer pre-pouring the medications will be completed and submitted into CCL by the due date. This proof of training will contain the name of the trainer, topic, attendees and length of training.
Type A
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [2] out of [2] facility resident records did not have the proper and updated medical assessments which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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The facility representative stated that all resident records will be updated to contain an updated medical assessment to address any, and all, care needs. A statement of correction, along with copies of the updated medical assessments, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 11/27/2024 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/26/2024 at 04:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that [1] out of [2] facility resident records did not have the proper and updated medical assessments which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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The facility representative stated that all resident records will be updated to contain an updated medical assessment to address any, and all, care needs. A statement of correction, along with copies of the updated medical assessments, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 11/27/2024 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/26/2024 at 04:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [2] facility personnel files did not possess a complete and updated personnel file missing required forms and documents which poses a potential threat to the health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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2
3
4
The facility representative stated that all facility personnel files will be updated to contain all required forms and documents at all times. A statement of correction, along with a copies of the updated forms and documents for the files, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 11/27/2024 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/26/2024 at 04:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A FRIENDLY ELDERLY CAREHOME, LLC
FACILITY NUMBER: 392701427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87506(b)(17)(A)
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [2] facility resident files did not possess a complete and updated file missing required forms and documents which poses a potential threat to the health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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2
3
4
The facility representative stated that all facility resident files will be updated to contain all required forms and documents at all times. A statement of correction, along with a copies of the updated forms and documents for the files, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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