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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200522
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:21:20 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 HOMEFACILITY NUMBER:
079200522
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:35CENSUS: 31DATE:
08/26/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cynthia Murphy, Nurse/AdministratorTIME COMPLETED:
03:45 PM
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On 08/26/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health & safety check and met with nurse (NM). LPA explained the purpose of the visit with NM. LPA spoke with administrator (ADM) who authorized NM to act on his behalf and sign the reports.

LPA observed routine COVID-19 symptoms checks done by staff wearing face masks at front entrance screening station (use of no touch temperature probe, visitors log, questionnaire, hand sanitizers, face masks). COVID-19 signages were observed at the front entrance, common hallways and bathrooms.

During the health and safety check, LPA observed a total of 7 staff members and 31 residents at the facility. LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be healthy and comfortable at the facility.

LPA observed pathway leading to the back exit door was obstructed by a hoyer lift. Administrator stated she had to put the hoyer lift in front of the back exit to prevent residents from opening the back exit leading to the parking lot.

Continued on next page, LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 08/26/2021
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During visit, LPA observed the following items needing replacements and or repairs:
  • Back exit entrance not locking properly. LPA observed a hoyer lift blocking back exit door to prevent residents from going out into the parking lot.
  • Three kitchen light panels were observed not working
  • Kitchen ovens are not working.
  • Kitchen sink pipe was leaking water on the floor
  • Blender for preparing pureed diets was observed cracked and chipped
  • Can openers for canned goods were not working
  • Pots and pans for cooking were observed old, bent and had peeled teflon linings due to overuse


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2021
Section Cited

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(d)The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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This requirement was not met as evidenced by broken back exit lock that poses a potential health & safety risk to residents in care.
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Type B
08/30/2021
Section Cited

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(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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This requirement was not met as evidenced by broken kitchen blender, sink pipes, panel lights, oven, pots & pans and can openers which posed a potential health & safety risk to residents in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3