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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200522
Report Date: 07/13/2022
Date Signed: 07/13/2022 04:57:48 PM

Substantiated


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
11/29/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211129130738
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:
07/13/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure that resident receive eyeglasses as prescribed

INVESTIGATION FINDINGS:
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On 07/13/22 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator and delivered investigation findings. LPA explained the purpose of the visit with administrator.

Allegation: Staff did not ensure that resident receive eyeglasses as prescribed
Investigation Finding: SUBSTANTIATED
Review of resident's (R1) physician's report (LIC602A) dated 09/21/20 show resident (R1) is visually impaired. LPA observed R1's functional assessment conducted by administrator dated 5/07/19 on R1's vision ability was never assessed. Administrator confirmed with LPA that R1's vision ability was never assessed annually. LPA observed a pair of eye glasses with holder inside a plastic bin located inside R1's bedroom cabinet. The preponderance of evidence has been met. Therefore, this allegation is substantiated.
Continued on next page, LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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 7
Control Number 15-AS-20211129130738
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: 07/13/2022
NARRATIVE
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Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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 via email.

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

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20211129130738
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: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited
CCR
87459(a)(7)
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The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to
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BY POC due date, administrator agreed to submit to CCLD a copy of R1's vision exam and prescription by his primary care physician to ensure R1's vision needs are met,
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(7)Physical condition, including:
(A) Vision...This requirement was not met as evidenced by resident's vision ability not assessed which posed a potential health & safety risk to resident 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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/29/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211129130738

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:
07/13/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident not allowed to converse with friends
Resident is not accorded privacy while in care
Staff are denying resident access to a cell phone

INVESTIGATION FINDINGS:
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On 07/13/22 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator and delivered investigation findings. LPA explained the purpose of the visit with administrator.

Allegation: Resident not allowed to converse with friends
Investigation Finding: UNSUBSTANTIATED
During investigation, staff confirmed R1 would sit in his Geri chair and socialize with other residents in the visitation area every week. Resident (R2) confirmed that he would converse with R1 twice a week whenever they are in the visitation area. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20211129130738
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: 07/13/2022
NARRATIVE
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Allegation: Resident is not accorded privacy while in care
Investigation Finding: UNSUBSTANTIATED
During investigation, staff (S2) stated they would give the house phone to resident (R1) whenever he has a telephone call and leave his bedroom. Prior to R1's admittance to hospice care, S2 stated R1 was able to take his phone calls independently and would call staff to get the house phone when done. After R1's admittance into hospice care on 06/20/21, S2 stated R1 could no longer hold the house phone independently so they would assist him and hold the house phone for him until he was done. Staff denied "cutting off" any calls for R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.


Allegation: Staff are denying resident access to a cell phone
Investigation FInding: UNSUBSTANTIATED
During investigation, staff (S2) stated that whenever resident (R1) has a phone call, they would take one of the house phones to R1 so he can talk to the caller. R1 told LPA that he does not get any phone calls any longer since he was admitted into hospice care on 06/20//2021. R1 stated he does not have a cell phone. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
11/29/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211129130738

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:
07/13/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff are not ensuring that resident has physical therapy sessions according to physician's instructions
Facility did not safeguard resident's personal belongings
Staff are not making sure that resident visits his doctor as necessary
Facility is odiferous
INVESTIGATION FINDINGS:
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On 07/13/22 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator and delivered investigation findings. LPA explained the purpose of the visit with administrator.

Allegation: Staff are not ensuring that resident has physical therapy sessions according to physician's instructions
Investigation Findings: UNFOUNDED
Based on interviews and record reviews, resident (R1) was admitted into hospice care on 06/30/2021 until 07/05/2022. Administrator stated hospice staff including hospice nurse, social worker, caregiver and physical therapist would visit R1 and help him with his activities of daily living (ADLs) and specific needs. This allegation has no reasonable basis. Therefore, it is unfounded.
Continued on next page, LIC 9099-C

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

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20211129130738
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: 07/13/2022
NARRATIVE
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Allegation: Facility did not safeguard resident's personal belongings
Review of resident's (R1) safeguard of property and valuables (LIC 621) show a play station in his bedroom on 12/09/2019 signed by administrator. No other items were declared. R1's eyeglass were observed to be inside his bedroom cabinet during visit. This allegation has no reasonable basis. Therefore, it is unfounded.


Allegation: Staff are not making sure that resident visits his doctor as necessary
Investigation Finding: UNFOUNDED
Based on interviews and record reviews, resident (R1) was admitted into hospice care on 06/30/2021 until 07/05/2022. Administrator stated hospice staff (Nurse, home health aide, social worker, physical therapist) would visit R1 and assist him with his care needs. Per administrator, once resident is under hospice care, the hospice care team ensures R1's needs are met and doctor's visits are not necessary. This allegation has no reasonable basis. Therefore, it is unfounded.


Allegation: Facility is odiferous
Investigation Finding: UNFOUNDED
During investigation, LPA toured the facility with administrator. LPA observed R1's bedroom did not have any smell of urine or feces inside. LPA did not observe facility to be malodorous. Therefore, this allegation is unfounded.

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

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7