079200522-6-22-2021-15-AS-DPAO-C48T5J-20210622142537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200522
Report Date: 06/22/2021
Date Signed: 06/22/2021 02:25:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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:	079200522
ADMINISTRATOR:	SANDHU, SUKHJIT		FACILITY TYPE:	740
ADDRESS:	1907 CAVALLO ROAD		TELEPHONE:	(925) 732-7364
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	35	CENSUS: 29	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Cynthia Murphy, Facility Nurse		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/22/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with facility nurse. LPA observed screening station located at the front desk with staff entering information on the visitor's log and using the no touch temperature probe for daily symptom screening (+/-) temperature & symptom check. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. LPA observed 5 staff wearing face masks during visit. Facility has a completed mitigation plan in place dated 04/22/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with facility nurse as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. Pathways were observed to be free of obstruction and fire hazards. Facility has a visitation area for residents to relax in. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FRIENDSHIP CARE HOME	FACILITY NUMBER: 079200522
	VISIT DATE: 06/22/2021

NARRATIVE

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All staff and residents have been fully vaccinated since February 11, 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Infection control designated leader is the facility nurse. Emergency food supplies were observed stored in the pantry. Sufficient supply of PPEs and incontinence supplies were observed stored in a locked separate shed in the backyard. Medications were observed locked in the medication room. Toxic chemicals were observed locked in the storage room located in the north wing. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged. Smoke and Carbon monoxide detectors were operational. LPA observed communal dining area with tables six feet apart.

Updated copies of the following documents were given by facility nurse to LPA during visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

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