079201172-3-14-2023-15-AS-KHOS-CQDMEY-20230329093332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 03/14/2023
Date Signed: 03/14/2023 01:04:37 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
03/13/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230313084925

FACILITY NAME:	FRIENDSHIP CARE HOME		FACILITY NUMBER:	079201172
ADMINISTRATOR:	SANDHU, SEEMA		FACILITY TYPE:	740
ADDRESS:	1907 CAVALLO ROAD		TELEPHONE:	(925) 732-7364
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	35	CENSUS: 31	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Cynthia Murphy, Manager on Duty Seema Sandhu, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility did not provide authorized representative a copy of resident's records

INVESTIGATION FINDINGS:

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On 03/14/23, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with manager on duty (MOD) and spoke with administrator (ADM) who authorized MOD to act on her behalf and sign the reports. LPA explained the purpose of the visit with ADM and MOD. LPA conducted interviews, gathered information and delivered investigation finding to MOD and ADM.

During visit, LPA confirmed with MOD that facility received Fed Ex package containing the request for copies of resident's (R1) records from authorized representative on 03/03/23. MOD stated she sent the Fed Ex package to ADM on 03/07/23. ADM confirmed with LPA during visit that she did not provide authorized representative a copy of R1's records.

Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230313084925

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: 079201172
	VISIT DATE: 03/14/2023

NARRATIVE

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Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility did not provide authorized representative a copy of R1's record is found to be substantiated.

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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230313084925

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: 079201172
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2023 Section Cited CCR 87506(c)(01)	1 2 3 4 5 6 7	All information and records obtained from or regarding residents shall be confidential. (1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.	1 2 3 4 5 6 7	By POC due date, ADM agrees to send authorized representative coplies of R1's records and submit to CCL proof of submission.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by facility not providing authorized representative a copy of resident's records which posed a potential health & safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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