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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:59:22 PM

Unsubstantiated


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
08/31/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220831093716
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: 31DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
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3
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5
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7
8
9
Questionable Death
Staff did not ensure that resident was adequately fed
Staff prevented residents from having visitors
Staff did not ensure that residents grooming needs were met
Facility staff does not answer the telephone
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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10
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12
13
On 06/30/23 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Questionable Death
Investigation Finding: Unsubstantiated
During investigation, IB investigator reviewed resident’s (R1) medical records from 07/01/2022 to 08/15/2022. Staff stated they found R1 unresponsive during their rounds at approximately 1330 hours on 08/06/22. Staff immediately called 911 and initiated CPR on R1. Paramedics arrived at approximately 1345 – 1400 hours and stabilized R1 who was transported to ER hospital and admitted on the same day at approximately 1413 hours. 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20220831093716
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: 06/30/2023
NARRATIVE
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Allegation: Questionable Death
Investigation Finding: Unsubstantiated
Continuation from page 1
R1’s chief complaint was cardiopulmonary arrest. R1 was pronounced deceased at the hospital approximately 1425 hours on 08/06/22. Review of R1’s Death Certificate show cause of death was Cardiovascular Disease. 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 that resident’s death was questionable due to neglect/lack of supervision by staff is unsubstantiated.

Allegation: Staff did not ensure that resident was adequately fed
Investigation Finding: Unsubstantiated
During investigation, staff (ADM) stated that R1 was a very picky eater and always ate breakfast daily. ADM stated R1 did not want to eat lunch and dinner at the facility since his admittance on 06/01/22. ADM stated she notified R1’s authorized representative (POA) about R1’s refusal to eat lunch and dinner. ADM stated staff offered him protein drinks (Boost) which he often refused. Review of weekly meal plans and random interviews with residents (R2, R3, R4) confirm they are fed three meals a day plus snacks by staff with a variety of meats, fruits and drinks. 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 that staff did not ensure that resident was adequately fed is unsubstantiated.

Allegation: Staff prevented residents from having visitors


Investigation Finding: Unsubstantiated
During investigation, staff (ADM, S1) confirmed with LPA that residents were allowed to be visited at the facility. Staff, residents and visitors were screened at the front entrance for COVID infection control. ADM stated they encouraged residents’ families and visitors to make an appointment prior to the visit. Review of visitors logs show staff allowed visits by family, friends and other agencies at the facility. 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 that staff prevented residents from having visitors is unsubstantiated.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220831093716
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: 06/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
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Allegation: Staff did not ensure that residents grooming needs were met
Investigation Finding: Unsubstantiated
During investigation, staff (ADM, S1) stated that resident (R1) was showered and groomed twice a week (Tuesdays & Saturdays PM) by staff. Review of weekly shower schedule show residents’ shower frequency each week. LPA also interviewed random residents (R2, R3, R4) who confirmed that staff assisted them with their activities of daily living (bathing, grooming, dressing, toileting). 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 that staff did not ensure that residents grooming needs were met is unsubstantiated.

Allegation: Facility staff does not answer the telephone
Investigation Finding: Unsubstantiated
During investigation, LPA observed staff (ADM, S1) answered the facility phone when called on 08/19/22, 8/23/22 and 09/01/22. ADM stated the facility has a general phone number (925-732-7364) given for residents’ families/authorized representatives (POAs) to call and leave a message for staff to return call. ADM also stated they have a second phone line (925-303-2978) available for residents and families to use when necessary. ADM stated the fax number (925-732-7196) at the facility is a separate number from both phone lines and is not connected to any of the phone lines. 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 that staff does not answer the telephone is unsubstantiated.

Exit Interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 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
08/31/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220831093716

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: 31DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not maintain a comfortable temperature for residents at all times
Staff did not maintain a medication log for residents
Staff overmedicated resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/30/23 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Staff did not maintain a comfortable temperature for residents at all times
Investigation Finding: Unfounded
During investigation, LPA observed facility temperature was maintained at 75 deg F during annual inspection on 07/08/22. Subsequent unannounced visits by LPA at the facility on 08/23/22 and 09/01/22 show facility temperature was maintained at 75 deg F. This department had investigated the complaint alleging that staff did not maintain a comfortable temperature for residents at all times. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220831093716
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: 06/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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Allegation: Staff did not maintain a medication log for residents
Investigation Finding: Unfounded
During investigation, LPA observed facility staff maintain Centrally Stored medication logs and medication administration records on residents. LPA reviewed copies of resident’s (R1) Centrally Stored medication logs and medication administration records with prescription dates filled by local pharmacy from 04/05/22 to 06/15/23. LPA also reviewed random residents’ (R2, R3, R4) prescribed medication records during visit. This department had investigated the complaint alleging that staff did not maintain a medication log for residents. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis.

Allegation: Staff overmedicated resident


Investigation Finding: Unfounded
During investigation, LPA reviewed resident’s (R1) Centrally stored medication logs and medication administration records dated 04/05/22, 06/10/22, 06/15/22, 06/21/22, 06/23/22 which showed R1 was not prescribed or administered any morphine by staff while at the facility. Staff (ADM, S1) stated they administered prescribed medications as ordered by the residents’ primary care physicians. Staff (ADM) stated R1 was not on hospice care and was not prescribed morphine by his doctor. This department had investigated the complaint alleging that staff overmedicated R1. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis.

Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 5 of 5