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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200522
Report Date: 10/25/2021
Date Signed: 10/25/2021 05:15:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2020 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20200921113259
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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Manthu SandhuTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility is odorous
Facility is dirty
INVESTIGATION FINDINGS:
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On 10/25/2021 Licensing Program Analysts (LPAs) L.Ibo and Jill Clancy-Czuleger arrived unannounced to deliver the findings on the above allegation. LPAs met with Manthu Sandhu, staff. LPAs called Manthu Sandhu and spoke with Manthu, administrator, who arrived after about 40 minutes. LPAs informed the purpose visit.

LPAs checked all rooms at the facility, room #12 is odorous, smells like a urine, wall appeared to be stained, with several scratches and paint is peeling & window blinds is broken. There are old head boards observed at the facility backyard area.

Based on the information obtained, the allegations are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.
...Continue to LIC9099C...

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2020 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20200921113259

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: 30DATE:
10/25/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff are not assisting residents with managing incontinence.
Food service is inadequate.
Residents are not getting their needs met.
INVESTIGATION FINDINGS:
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On 10/25/2021 Licensing Program Analysts (LPAs) L.Ibo and Jill Clancy-Czuleger arrived unannounced to deliver the findings on the above allegation. LPAs met with Manthu Sandhu, staff. LPAs called Manthu Sandhu and spoke with Manthu, administrator, who arrived after about 40 minutes. LPAs informed the purpose visit.

LPAs conducted interviews with four, residents get enough food, residents eat at least 3x a day. LPAs observed incontinent care products available for the residents in care. Per S2 staff checks the residents at least every 2 hours, facility has a log to document residents being change on their incontinent products. Residents appeared to be well groomed & with clean clothing, 4 residents were interviewed and said they are well taken care of by staffs and like living at the facility.
...Continue LIC9099C..
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20200921113259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/25/2021
NARRATIVE
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Based on interviews and documentation reviewed the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Exit interview conducted and a 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20200921113259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/25/2021
NARRATIVE
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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, LIC9098 Proof of Correction form 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20200921113259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
11/05/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation (a) 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 evidence by:
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Administrator will hire professional steam cleaners to clean the residents rooms with carpeted floor. Administrator will change/fix all facility window blinds that appeared to be broken. Adminsitrator will need to re-paint room #12's wall.
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Based on LPA’s observations during the visit, LPAs checked all rooms at the facility, room #12 is odorous, smells like a urine, wall appeared to be stained, with several scratches and paint is peeling & window blinds is broken, this posed an potential health and safety risk to residents in care.
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Proof of evidence needs to submit to CCL on POC date.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 5