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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701427
Report Date: 01/15/2025
Date Signed: 01/21/2025 09:50:32 AM

Document Has Been Signed on 01/21/2025 09:50 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:
01/15/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Samuel Saahene, Mirasol Kasai and Anabelen VallartaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Unannounced Plan of Correction visit made out to this facility on 01/15/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Samuel Saahene and Mirasol Kasai. A brief interview was conducted with the facility staff persons at this time. This LPA requested that the facility staff persons go ahead and contact the facility designated Administrator, Sharon Drequito, to inform her that CCL was present at this time.
Current census was 2 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior post licensing visit conducted on 11/16/2024. This visit was to follow up on the Plans of Correction that were due.
The following deficiencies were observed and cited on 11/26/2024:
  • 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.

  • 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:

  • 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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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: 01/15/2025
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  • 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.

  • The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or non ambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether non ambulatory status is based upon the resident's physical condition, mental condition or both.

  • The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

  • 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 facility did complete the Plans of Correction and provided all of the required forms and documents at this time.

Plan of Correction clearance letters were printed and copies were provided to the facility staff person at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

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

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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