079201172-10-5-2023-15-AS-KHOS-CWFS4T-20231009133313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 10/05/2023
Date Signed: 10/05/2023 01:43:44 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
10/03/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231003161047

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:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cynthia Murphy, Manager on Duty		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility staff not treating for scabies at facility

INVESTIGATION FINDINGS:

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On 10/05/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit, met with manager on duty (MOD), gathered information and delivered investigation finding of above allegation. LPA explained the purpose of the visit with MOD.

During investigation, the department obtained the following documents from manager on duty - staff roster, residents roster, admission agreement, physicians report, ID/Emergency information, centrally stored medication logs, medication administration records, public health and incident reports.

Allegation: Facility staff not treating for scabies at facility
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM) who stated that resident (R1) was initially sent to the hospital on 09/04/23 due to low blood pressure & oxygen. R1 returned from the hospital on 09/08/23 with new medications. ADM stated staff noticed R1 itching on 09/10/23 and consulted with his health care team who stated it could be his medications side effect. On 09/30/23, R1 was again sent back to the hospital due to a change in condition (weakness). Continued on next page, LIC 9099-C

Unsubstantiated

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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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-20231003161047

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: 10/05/2023

NARRATIVE

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The hospital evaluated R1 and confirmed he had scabies on 10/02/23. ADM immediately contacted local public health and implemented infection control plan.

ADM stated all residents’ linens and clothing were hot water washed and cleaned on 10/03/23. Additional staff was hired to implement infection control. ADM stated all staff and residents were evaluated for scabies and only one resident (R2) displayed itching. ADM stated R2 is scheduled to see his doctor on 10/06/23 for evaluation & treatment. ADM stated R1 is scheduled to come back from the hospital on 10/05/23.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility staff are not treating for scabies and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility staff are not treating residents for scabies is unsubstantiated.

No deficiencies cited during visit. Exit interview conducted 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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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