079201172-11-8-2023-15-AS-KHOS-CY2QM4-20231129111656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:59:56 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
11/02/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231102093631

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: 30	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Seema Sandhu, Administrator Cynthia Murphy, Manager on Duty		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility withheld resident's personal belongings

INVESTIGATION FINDINGS:

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On 11/08/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with manager on duty (MOD), gathered information and delivered investigation findings of above allegations. 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, hospice records, Safeguard of property & valuables form and incident reports.

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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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-20231102093631

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: 11/08/2023

NARRATIVE

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Allegation: Facility withheld resident’s personal belongings
Investigation Finding: Substantiated
During investigation, LPA interviewed staff (MOD) who confirmed that they withheld resident’s (R1) personal belongings from authorized representative (POA) around 1:40PM on 11/01/23 because POA refused to sign for R1's remaining personal items being collected that day which were a wall decor wreath, black IPad, photo album binder, rose colored floral twin quilted bedspread and eye glasses with red case. Review of incident report dated 11/01/23 showed R1's family members came to pick up R1's personal belongings around 1:40PM and became aggressive with staff (pushing staff against the front door, grabbing R1's personal items, yelling at staff) when they refused to sign the release form given by staff for R1's remaining personal items. Based on the department’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 withheld resident’s personal belongings was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20231102093631

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: 11/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/30/2023 Section Cited CCR 87217(j)(2)	1 2 3 4 5 6 7	The executor or the administrator of the estate shall be notified by the licensee, and the cash resources, personal property, and valuables surrendered to said party.	1 2 3 4 5 6 7	By POC due date, administrator agreed to complete and submit in-service staff retraining certificates on how to properly safeguard & surrender residents’ personal belongings & valuables in compliance with Title 22 Section 87217(j)(2).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff withholding resident’s personal belongings to authorized representative on 11/01/23.	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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
11/02/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231102093631

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: 30	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Seema Sandhu, Administrator Cynthia Murphy, Manager on Duty		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not prevent resident's personal belongings from becoming damaged.

INVESTIGATION FINDINGS:

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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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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-20231102093631

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: 11/08/2023

NARRATIVE

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Allegation: Facility did not prevent resident's personal belongings from becoming damaged.
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff and reviewed resident (R1) documents. Staff (MOD) stated that when R1 passed away on 01/12/23, R1's family member collected her personal belongings inside her bedroom which were a cloth suitcase, photo albums, box of clothes, bible, black fanny pack, pillow, red IPad, rose bed sheet set. MOD stated she observed all items collected on 01/12/23 were in good condition and that the bible had no water damage. Review of R1's property & valuables form dated 01/12/23 showed R1's listed personal items were released and signed by staff and R1's family member that day with no written observation of damage to any of the items collected.

During visit on 11/08/23 at 1:45PM, LPA observed R1's remaining personal items (wall decor wreath, photo album, black IPad, eye glasses in red case and twin quilted bedspread) were not damaged and kept locked inside the facility's office for safekeeping. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility did not prevent resident's personal belongings from becoming damaged 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 did not prevent resident's personal belongings from becoming damaged is unsubstantiated.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

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