079201172-11-4-2022-15-AS-KHOS-CL2M6D-20221110081945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:49:37 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
10/27/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20221027103728

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: 32	DATE:	11/04/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Cindy Murphy, Administrator Seema Sandhu, Licensee		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Licensee did not issue a refund

INVESTIGATION FINDINGS:

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On 11/04/22 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator (ADM) and spoke with licensee (LC) on the phone. LPA explained the purpose of the visit with ADM and LC.

Based on record reviews and interviews, resident (R1) was admitted at the facility on 08/06/22 under hospice care. ADM confirmed R1's authorized representative (POA) made timely monthly payments for R1's care and supervision per signed admission agreement. On 09/26/22, R1 passed away at the facility and his personal belongings were removed on the same day.

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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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 3

Control Number 15-AS-20221027103728

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: 11/04/2022

NARRATIVE

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LC confirmed with LPA that a refund check was issued to POA by mail dated 10/15/22. LPA observed issuance of the refund check was 5 days past the 15 day refund period when R1's personal belongings were removed (09/26/22) from the facility. LPA discussed refund check total with LC based on the remaining 9 days total refund due to POA for the month of September 2022. On 11/04/22, LC issued another refund check of $45 payable to POA as full and final payment of R1's September 2022 refund.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be SUBSTANTIATED.

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

Exit interview conducted. Appeal Rights 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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20221027103728

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: 11/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/04/2022 Section Cited CCR 87507(g)(5)(A)	1 2 3 4 5 6 7	Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652	1 2 3 4 5 6 7	Administrator corrected deficiency during visit. Final refund check of $45 sent to R1's POA dated 11/04/22.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by late refund of R1's paid September 2022 when R1 passed away on 09/26/22 which was in violation of Title 22 Section 87507 refund regulation.	8 9 10 11 12 13 14	Licensee and administrator understood Title 22 Section 87507 and will comply with Admission agreement regulations including refund policies.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC9099 (FAS) - (06/04)

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