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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:38:48 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
09/29/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220929165630
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: 34DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Esmeralda Vega, SupervisorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not adhere to the admission agreement requirements
INVESTIGATION FINDINGS:
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On 10/07/2022 at 11:15 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegation. LPAs met with Supervisor, Esmeralda Vega and explained the purpose of the visit. LPAs spoke to Administrator over the phone and Administrator is not available.

During the complaint investigation, LPAs interviewed staff and reviewed records. Based on interview with S1 and record review of resident's Admission Agreement, there is a non-refundable policy regardless of removal of the resident's personal property upon after a resident's death. However, it is in violation of Title 22 regulation 87507(g)(5)(A).

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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 4
Control Number 15-AS-20220929165630
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: 10/07/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation IS found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
09/29/2022 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20220929165630

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: 34DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Esmeralda Vega, SupervisorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not issue a proper refund.
INVESTIGATION FINDINGS:
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On 10/07/2022 at 11:15 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegation. LPAs met with Supervisor, Esmeralda Vega and explained the purpose of the visit. LPAs spoke to Administrator over the phone and Administrator is not available.

During the complaint investigation, LPAs interviewed staff and reviewed records. Based on record review and interview with staff, resident passed away on 9/26/22. S2 stated resident's hospice equipment and personal items were removed from resident's room the same day. According to S2, resident's room was move-in ready by 9/27/2022. The facility is still within the 15-day refund policy period.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator over the phone and a copy of this report provided with Supervisor.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220929165630
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: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
87507(g)(5)(A)
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87507(g)(5)(A) ADMISSION AGREEMENT
(5) Refund conditions.(A) 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.
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By POC date, Administrator will amend admission agreement in accordance to regulation and submit a copy to CCL.
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This requirement is not met as evidenced by: Based on record review and interview, the Licensee did not comply with the regulation cited above by stating there is a non-refundable policy which poses a potential personal rights to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4