079201172-6-30-2023-15-AS-DPAO-CTB2BH-20230630171510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201172
Report Date: 06/30/2023
Date Signed: 06/30/2023 05:15:43 PM

Document Has Been Signed on 06/30/2023 05:15 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 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:	06/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Cynthia Murphy, Administrator		TIME COMPLETED:	05:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/30/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand washing signs were observed posted in common areas. Facility has a 30-day supply of PPEs, paper, medications locked in medication room cabinets. Comfortable temperature was observed at 77 deg F per thermostat reading. Hot water temperature was measured at 116 deg F. Fire extinguishers were last inspected on 01/05/23 and observed fully charged. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 3 staff and 3 resident interviews during visit. The following deficiencies were observed during inspection: Automatic front gate damaged Insufficient food supply in the kitchen (not enough for census of 31 residents) Broken kitchen vents Lifting flooring between Shower 2 entry and hallway Peeling walls in Shower #2 Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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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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: 06/30/2023

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/03/23:
 LIC500- Personnel Report
 Resident Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

Deficiencies are 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: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/30/2023 05:15 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: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Facility staff did not comply with Section 87303 (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 was not met as evidenced by broken gate, kitchen vents and damaged shower walls and flooring which posed a potential health & safety risk to residents in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator agreed to fix the following on or before POC due date of 7/28/23: Broken automatic gate Broken kitchen vents Damaged Shower# 2 walls & flooring Lifting floor boards at Shower#2 entrance and hallway

Type B

Section Cited

CCR

87555(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Facility staff did not comply with Section 87555 (a): 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. This requirement was not met as evidenced by insufficient 2 day perishable food supply which posed a potential health and safety risk to residents in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase 2 day perishable food supply on 06/30/23 and submit food receipts to LPA on 07/01/23. Administrator also agreed to maintain adequate food supply for all residents in the quantity and quality required to meet residents needs.

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: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

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