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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708648
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:58:58 PM

Document Has Been Signed on 12/18/2024 03:58 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:FRIENDSHIP HOUSEFACILITY NUMBER:
430708648
ADMINISTRATOR/
DIRECTOR:		HAND, ELIZABETHFACILITY TYPE:
740
ADDRESS:1511 PRINCETON DRIVETELEPHONE:
(408) 665-0911
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Licensee Elizabeth SolorioTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Elizabeth Solorio. During the visit, LPA observed 5 residents and 3 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 4 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA toured the garage, which is being used as storage and a laundry area. There was no obstruction to block the walkways.

While touring the 2 bedrooms that are directly next to each other, LPA observed the flooring next to the entrance to the bathroom. The flooring sinks when stepped on and has damage. (Photograph was taken.) LN stated she has been working on fixing it. LN stated the flooring has been damaged for about a month. While touring bedroom #1, LPA observed one of the windows did not have a screen. (Photograph was taken.) While touring the living room, LPA observed the sliding screen door was missing. (Photograph was taken).

While touring the backyard of the facility, LPA observed the fence, had a wooden slab that was missing, which left an area of the neighbors backyard exposed. LPA also observed a Canopy tent directly outside of the LN's room, which was damaged and had holes. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 74 degrees F, and hot water temperature was measured at 107 degrees F in resident bathrooms. Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: FRIENDSHIP HOUSE
FACILITY NUMBER: 430708648
VISIT DATE: 12/18/2024
NARRATIVE
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Fire extinguisher was serviced in December 12, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 1, 2024.

LPA reviewed facility records for 3 residents. Resident R1 Physician's Report, dated 4/20/2017, states resident has a neurocognitive disorder. R1's newest Appraisal/Needs and Services Plan, is dated December 10, 2023. LN stated she did not have an updated physicians report or Appraisal/Needs and Services plan. R2's physician's report is dated October 25, 2012. LPA advised LN to have R2's physicians report updated, and to ensure its updated frequently enough to have up to date information. LN stated she would send a copy of R2's updated physicians report to LPA. LPA requested to reviewed R2's Appraisal/Needs and Services Plan. LN stated she could not find it.

LPA reviewed 3 staff records. LN stated Staff S2's first aid documentation was not in the home, but it was completed and is current. LN stated Staff S3 has already signed up for his/her first aid training on December 21, 2024. LN stated she would send LPA documentation the first aid training has taken place. LPA requested to review staff training documentation for the year 2024. LN stated she has not conducted any training for her staff. LPA reviewed 3 resident medications and centrally stored medication records.

LPA requested copies of the following documents be sent to LPA:
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. Qualifications of Administrator (Certificate)
6. Please review your facility program for updates (incorporating new laws and/or regulations)

LPA provided Dementia Care and RCFE regulation updates flyer.

Deficiencies are being cited during today's visit. This report was reviewed with Licensee Elizabeth Solorio and a copy of the signed report was provided. Appeal rights were provided.
Page 2 Out of 2. END OF REPORT
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/18/2024 03:58 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/18/2024 at 03:15 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FRIENDSHIP HOUSE
FACILITY NUMBER: 430708648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. LPA observed the following was in disrepair: the flooring next to the entrance to the bathroom, bedroom #1 had a window without a screen, The living room sliding screen door was missing, the backyard fence had a wooden slab that was missing, Canopy tent directly outside of the LN's room was damaged. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure The facility shall be safe and in good repair at all times. ADM stated she will send LPA written plan of action by POC date, 12/25/2024.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to reviewed R2's Appraisal/Needs and Services Plan. LN stated she could not find it. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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LN stated she would create a new Appraisal/Needs & Services plan for R2. LN stated she would send a copy LPA by POC date, 12/25/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2024 03:58 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/18/2024 at 03:15 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FRIENDSHIP HOUSE
FACILITY NUMBER: 430708648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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. Resident R1 Physician's Report, dated 4/20/2017, states resident has a neurocognitive disorder. R1's newest Appraisal/Needs and Services Plan, is dated December 10, 2023. LN stated she did not have an updated physicians report or Appraisal/Needs and Services plan. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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LN stated she would get an updated physicians report and Needs & Services Plan for R1. LN stated she would send copies of these updated forms to LPA by POC date, 12/25/2024.
Type B
Section Cited
CCR
87411(c)
87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above. LPA requested to review staff training documentation for the year 2024. LN stated she has not conducted any training for her staff. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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LN stated she will send LPA a written plan of action on how she will ensure her staff is trained annually. ADM stated she will send this written plan of action to LPA by POC date, December 25, 2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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