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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 04:40:50 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
09/30/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220930151105
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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Residents are being locked inside the facility.
Staff are not adhering to COVID-19 infection control

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 course of the investigation, LPAs toured facility, reviewed records, collected documents and interviewed staff and residents. It was alleged residents are being locked inside the facility. Based on information obtained, staff were looking for the key to the front main entrance and visitors were unable to leave facility. At 12:45 PM, LPAs observed a key attached to the door. S1 and S2 stated that staff keeps the front main entrance locked so residents who are diagnosed with dementia cannot leave the facility.

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 5
Control Number 15-AS-20220930151105
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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It was alleged facility staff are not adhering to COVID-19 infection control. Based on information obtained , facility sometimes does not screen visitors and does not have them sign the sign-in log. Based on observation at 11:35 AM, LPAs observed a visitor was not screened and did not sign the sign-in log.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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 5
Control Number 15-AS-20220930151105
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 A
10/07/2022
Section Cited
CCR
87468.1(a)(6)
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87568.1(a)(6) PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building....
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By POC date, Administrator will review regulations, cease locking the exterior doors, and submit a self-certification letter to CCLD. In addition, Administrator will conduct staff training and submit a copy of training agenda with staff signatures.
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This requirement is not met as evidenced by: Based on observation and interviews, Licensee did not comply with the regulation cited above by locking front main etrance door with a key which poses an immediate personal rights to persons in care.
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Type B
10/07/2022
Section Cited
CCR
87405(d)(2)
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87405(d)(2) ADMINISTRATOR - QUALIFICATIONS AND DUTIES
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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By POC date, Administrator will review PIN 22-28-ASC and conduct in-service training with staff, and submit a copy of training agenda with staff signatures to CCLD.
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This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above by visitor was not screened and requested to sign in which poses a potential health and safety risk 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: 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
09/30/2022 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20220930151105

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 provide a call button to resident.
Facility did not assist resident's needs at night time.
Facility did not maintain adequate temperature for the resident's room.
Staff are providing care and supervision while under the influence of alcohol or drugs
Lights in resident's room is in disrepair.
Facility did not issue resident a 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 course of the investigation, LPAs toured facility, reviewed records, collected documents and interviewed staff and residents. It was alleged facility did not provide a call button to resident. Based on information obtained, resident (R1) was not provided a call button. However, facility is not required to have a call button since it only has one floor. 5 of 5 staff stated residents are checked every 30 minutes to 2 hours by staff.

REPORT CONTINUES ON 9099C
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: 4 of 5
Control Number 15-AS-20220930151105
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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It was alleged staff did not assist resident's needs at night time. No forthcoming information from resident 1. However, based on interview with 5 residents, 5 of 5 stated that staff assists them in the evening when they need assistance.

It was alleged facility did not maintain adequate temperature for the resident's room. LPAs observed room temperature for both wings are set to 77 degrees F in the right wing and 76 degrees F in the left wing. LPAs interviewed 5 residents and 5 of 5 stated they have no issue with their room temperature. S1 stated when the HVAC was in disrepair last year, all residents affected were provided a fan in their rooms.

It was alleged staff are providing care and supervision while under the influence of alcohol or drugs. However, based on interview with 5 staff and residents, 5 of 5 staff and 5 of 5 residents stated they have not observed staff being under the influence of drugs or alcohol while providing care.

It was alleged lights in resident's room is in disrepair. Based on observation, lights in R1's room is in disrepair. However, S1, S2 and S3 stated that R1 was provided a lamp. LPA was unable to prove or disprove allegation.

It was alleged facility did not issue resident a refund. R1 was admitted to the hospital on 9/21/22. Based on information obtained by reporting party, R1's family member decided to not have R1 return to the facility. S1 and S2 stated resident did not want to return to the facility. LPAs reviewed R1's records and did not observe an eviction notice was issued to R1. LPAs discovered during a record review that there is a no refund policy regardless of how many days a resident stayed.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided with Supervisor.
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: 5 of 5