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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 08/23/2022
Date Signed: 08/23/2022 04:54:38 PM

Unfounded


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
08/17/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220817172538
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:
08/23/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not dispense medication as prescribed
Licensee did not maintain current record of resident’s medications
INVESTIGATION FINDINGS:
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On 08/23/22 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with administrator, gathered information, conducted interviews and delivered investigation findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Facility staff did not dispense medication as prescribed
Investigation Finding: Unfounded
Based on interviews and record reviews, resident (R1) confirmed with LPA during visit that he refused all the prescribed medications from his doctor because he did not feel like taking them on 08/01 and 08/02. As a result, he experienced shortness of breath and chest pains on 08/03, sent to the hospital by staff for evaluation/treatment and was released back to the facility the same day with no changes to his baseline. Thus, the allegation that facility staff did not dispense R1's medication as prescribed is unfounded.

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: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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 2
Control Number 15-AS-20220817172538
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: 08/23/2022
NARRATIVE
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Allegation: Licensee did not maintain current record of resident’s medications
Investigation Finding: Unfounded
Review of resident's (R1) medication administrator records dated 08/01/22 to 08/31/22 show R1 had 10 prescription medications (Clonidine, Atorvastatin, Amlodepine, Gabapentin, Lisinopril, Omeprazole,Valproic Acid,Zinc Oxide,Stool softener, aspirin) and 1 PRN (Acetamenophin) administered and signed by staff on a daily basis. Thus, the allegation that licensee did not maintain current record of R1's medications is unfounded.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2