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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201172
Report Date: 07/08/2022
Date Signed: 07/08/2022 02:04:23 PM


Document Has Been Signed on 07/08/2022 02:04 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 HOMEFACILITY NUMBER:
079201172
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:35CENSUS: 30DATE:
07/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Seema Sandhu, Applicant/LicenseeTIME COMPLETED:
02:30 PM
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On 07/08/22 at 1:10PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a Change of Ownership Pre-licensing Required inspection. LPA met with Applicant/Administrator and explained the purpose of the visit. The facility currently has 31 residents.

LPA toured facility including but not limited to 35 apartments with dedicated bathrooms, kitchen, common areas and backyard. LPA observed COVID signages posted at the front entrance, common areas, sinks, bathrooms. LPA observed screening station at the front desk with no touch temperature probe, hand sanitizers, additional face masks, visitors logs. COVID infection control plan (LIC 9282) was observed complete. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 75 degrees F and hot water temperature was maintained at 112 degrees F. First-aid kit was observed to be complete. Medications, sharps and disinfectants/chemicals were observed locked. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 06/04/22. Pre-licensing is complete and there are no deficiencies observed during visit.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report was provided to Applicant via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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