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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201172
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:43:34 PM


Document Has Been Signed on 06/16/2022 03:43 PM - It Cannot Be Edited

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:
079201172
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:35CENSUS: 30DATE:
06/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cynthia Murphy, Administrator
Esmeralda Vega, Med Tech		TIME COMPLETED:
03:45 PM
NARRATIVE
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On 06/16/22 at 1:40PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced pre-licensing visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

LPA observed 3 staff wearing face masks during visit. COVID-19 screening station is at the front desk where no touch temperature probe, visitors logs, additional face masks, hand sanitizers and gloves are available for visitors, residents and staff. LPA observed 7 residents not wearing face masks in the visitation areas. ADM stated that they encourage them to wear face masks but they refuse while inside the facility. Antigen mass testing were completed on 06/06 & 06/10 by ADM & floor supervisor to all residents and staff. Test results were all negative. ADM stated CC Public Health cleared facility yesterday, 6/15/22 of COVID infection. LPA requested ADM to email a copy of CC Public Health clearance from ADM during visit.

LPA toured the facility with ADM and observed the following deficiencies:
  • Insufficient food (2 day perishables and 1 week non-perishables) in the kitchen pantry, refrigerators and freezers
  • Insufficient staff - Current staffing (AM shift 3 caregivers, floor supervisor & administrator M- F; PM shift is 2 caregivers, one Med Tech, one activity & cook staff: NOC shift 1 caregiver & 1 Med Tech). One resident (R1) requires one on one care.
  • Common hallway in the east wing has laminated flooring that is peeling
  • Common bathroom flooring in the east wing is deteriorating
  • Broken blinds inside residents' bedrooms and common hallway doors
  • Warm temperature inside facility - thermostat reading at 82 deg F

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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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Document Has Been Signed on 06/16/2022 03:43 PM - It Cannot Be Edited

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: 079201172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited

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General food service requirements
The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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This requirement was not met as evidenced by insufficient perishable and non perishable food in the kitchen pantry which posed an immediate health & safety risk to residents in care
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Type A
06/17/2022
Section Cited

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Personnel Requirements
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs
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This requirement was not met as evidenced by insufficient staff to meet residents' needs which posed an immediate 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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/16/2022 03:43 PM - It Cannot Be Edited

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: 079201172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited

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Maintenance & Operation
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.
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This requirement was not met as evidenced by deteriorating floorings, warm temperature and broken window blinds 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: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 079201172
VISIT DATE: 06/16/2022
NARRATIVE
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Pre-licensing is incomplete with deficiencies to be resolved by 07/16/22.

A follow-up Pre-licensure LIC 809 will be generated upon resolution of deficiencies.

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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4