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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200522
Report Date: 10/25/2021
Date Signed: 10/25/2021 05:11:53 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: 29DATE:
10/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Manthu SandhuTIME COMPLETED:
05:35 PM
NARRATIVE
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On 10/25/2021 Licensing Program Analysts (LPAs) L.Ibo and Jill Clancy-Czuleger arrived unannounced to conduct case management visit in related to another visit conducted.

During facility tour, LPAs observed 3 peanut butter jars expired on August 10,2021, the peanut butter jars are opened and located on the kitchen counter. There is a green freezer located at the facility kitchen was observed to be stained with food on the bottom at also appeared to be sticky with some food juices. These observations were showed to Administrator Manthu Sandhu.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction (POC) by plan of correction due date and any repeat violations within 12-month period may result in civil penalties.



Deficiency and plan and proof of correction were discussed with Manthu Sandhu.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 2
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: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited

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87555d(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained
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This requirement was not met as evidenced by; based on LPAs observation,3 peanut butter jars with an expiration date of August 21,2021 was observed in the kitchen counter, one of the peanut butter jar was opened which pose an potential health and safety risk to residents in care.
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Type B
11/01/2021
Section Cited

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80076 Food Services (a) In facilities providing meals to clients, the following shall apply:(19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.
This requirement is not met as evidence by:
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Based on LPAs observations the licensee did not comply with regulations above, a green freezer located at the facility kitchen was observed to be stained with food on the bottom at also appeared to be sticky with some food juices which pose an potential health and 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2