342701289-10-6-2023-27-AS-TTRG-CWCUUD-20231006155321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:53:25 PM

Document Has Been Signed on 10/06/2023 03:53 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	FRIENDLY ISLAND HOME		FACILITY NUMBER:	342701289
ADMINISTRATOR:	MATAELE, MOLINI		FACILITY TYPE:	740
ADDRESS:	9145 ROTHSAY WAY		TELEPHONE:	(916) 670-0489
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY:	6	CENSUS: 1	DATE:	10/06/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Molini Mataele		TIME COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/6/2023 at 2:00 PM, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA met with Applicant, Molini Mataele who assisted LPA in today’s inspection. It was learned that this facility will be licensed to serve up to 6 ambulatory residents of which 2 may be non-ambulatory in bedroom #1 only. There was 1 resident in care during today's pre-licensing visit. LPA toured the facility with Applicant Molini Mataele. Dining area, living area, and all other areas intended for client use were toured and observed to be furnished and maintained in compliance at this time. LPA observed no obstruction of emergency exits. Fire extinguisher was observed and is up to date. Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Medication cabinet was observed. First aid kit was observed to be present and contained all required components at this time. A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the residents were observed to be insufficient to meet the needs of the residents at this time. A tour of the client bathrooms was conducted. Hot water temperatures were taken and measured at 108.0 degrees Fahrenheit. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FRIENDLY ISLAND HOME	FACILITY NUMBER: 342701289
	VISIT DATE: 10/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed.
A tour of the laundry room and garage was conducted.

During today's visit, LPA observed the facility was overall in good repair. There were a few items that need corrected. The following items that need to be corrected were as follows:

- Garage door was unable to close and need to be repaired or replaced.
- Air vent in bathroom #1 is not working and need to be repaired or replaced.
- Each resident rooms need to be well furnished and in good repair.
- Backyard shall be kept free of debris and obstruction of potential hazard.
- Windows, doors, and baseboards were not clean.
- Cleaning supplies need to be kept lock and away from the kitchen.
- Faucet in bathroom #1 is not in good repair and need to be repaired or replaced.

As a result, the facility has not passed today's pre-licensing inspection. LPA Truong will return to the facility when the corrections have been made. Applicant was informed to call LPA Truong when the correction has been completed.

An exit interview was conducted, and a copy of this report was given to the applicant.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2