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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 11/05/2025
Date Signed: 11/05/2025 04:20:42 PM

Document Has Been Signed on 11/05/2025 04:20 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FRIENDLY ISLAND HOMEFACILITY NUMBER:
342701289
ADMINISTRATOR/
DIRECTOR:		MATAELE, MOLINIFACILITY TYPE:
740
ADDRESS:9145 ROTHSAY WAYTELEPHONE:
(916) 670-0489
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 1DATE:
11/05/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Griselda MartinezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 11/5/25, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at facility unannounced to conduct a Case Management -legal quarterly visit. LPA Cynthia Tamayo met with staff, Griselda Martinez(S1) and explained the purpose of the visit. S1 contacted Administrator Molini Mataele (FDA) to let them know LPA was at the facility but they did not answer. FDA called LPA back at 11:30 AM but did not respond to phone calls at 12:09 and 3:38 PM. An entrance interview was conducted.

The purpose of the visit today is to conduct a quarterly visit, the department has issued a two year probational license thru 2/5/2027. Current census is one (1) resident. The facility is licensed to serve Approved for six (6) ambulatory age range 60 and over, of which two (2) may be non-ambulatory in room 1. Hospice waiver for one is granted. The census is 1 and 1 staff. All staff are criminal background cleared.

LPA Tamayo followed up with the following contents/terms of the Stipulation:
1. Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly. LPA observed the facility is not in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly. LPA observed the facility was not free from odors and there was evidence of an existing mouse and/or insect problem in the kitchen. LPA observed S1 take out the trash at 3:55PM. LPA observed a pile of dirty clothes in R1's bathroom; Staff reported the washing machine stopped working about 2-3 weeks ago and they tried to have someone repair it two weeks ago but were unsuccessful. Both machines were removed due to it not working and a new washing machine and dryer machine will be installed. FDA stated laundry is being completed off-site until a replacement is completed. A new LIC 602 evaluation will be requested from R1's physician due to them not being able to reposition on their bed.
Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FRIENDLY ISLAND HOME
FACILITY NUMBER: 342701289
VISIT DATE: 11/05/2025
NARRATIVE
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LPA observed there was no mobility device placed was within accessible distance from R1. LPA observed staff place a wheelchair near R1 during this visit. LPA also observed S1 feed lunch to R1 from 12:00PM -12:30PM. LPA observed one changing took place fro R1 during this visit.

2. Maintain current, personnel records of each employee at the facility and ensure all employees have a current certificate of CPR and first aid training on file at the facility. LPA reviewed three staff records, all staff has a current CPR and first aid training on file at the facility.

3. Post the Stipulation in a conspicuous place at the facility for the duration of the probationary period.
LPA observed the Stipulation Order posted in bulletin board in a common area.

4. Maintain an accurate, complete, and current client roster which must be made available to the Department upon review. LPA observed the most current roster is dated 8/16/2025 and needs to be updated due to two out of three residents are no longer living in the facility.

LPA reviewed the resident records for Resident 1 (R1) in which the completed 627C consent form was still not added to the resident's file. LPA reviewed the Medication Administration Records (MARS) for one resident (R1) and observed FDA did not complete the MARS on 11/3/25.

LIC 9020 register of facility clients/residents dated 8/16/25, lists two former residents, a current version of LIC 9020 was requested.

LIC 500 Personnel Record dated 8/16/25, lists is not up to date, an updated LIC 500 was requested.

LPA requested to review personnel records of each employee at the facility. Administrator, S1, and S3 have a current certificate of CPR and first aid training on file at the facility. There is no training verification for any resident available for review.

LPA observed Administrator certificate # 600674740 and expired 9/15/202 and there is not verification of an updated administrator certificate is in processes. FDA stated they paid the renewal fee and submitted the hours verification for the Administrator certificate renewal via the online portal, however they are not able to provide any verification at this time due to being at work.
Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 04:20 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 11/05/2025 at 12:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRIENDLY ISLAND HOME
FACILITY NUMBER: 342701289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties (a) ... shall have a qualified and currently certified administrator ... administrator shall have .... freedom from other responsibilities ... on the premises a sufficient number of hours to permit adequate attention to the management and administration ...
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Licensee will submit valid administrator certificate for the designated administrator by 11/14/25. Licensee will also submit a plan to ensure compliance with 87405(a); in which the designated qualified administrator has freedom from other responsibilities and is on the premises a sufficient number of hours to
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This requirement was not met as evidence by record review in which there is no current administrator cerificate for Molini Mateaele (FDA). Additionally, LPA observed FDA was not avaialble in person nor via immidiate phone call on 8/12/25 and 11/5/25. This poses a potential health and safety risk to residents in care.
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permit adequate attention to the management and administration.
Type B
11/14/2025
Section Cited
CCR888(b)(27)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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Licensee will submit a plan to ensure the kitchen area to ensure it is sanitary and free of litter, rodents, vermin and insects, including ensure food storage areas and all food items are inspected before storing by 11/14/25. Licensee will also schedule pest control services to evaluate the facility for services by 11/14/25.
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This requirement was not met as evidence by interviews and observations. LPA observed there are mouse traps and pantry moths in the pantry. FDA stated mice have came in the home "from the outside". This poses a potential health and safety risk to residents 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FRIENDLY ISLAND HOME
FACILITY NUMBER: 342701289
VISIT DATE: 11/05/2025
NARRATIVE
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5. All required records shall be maintained in a safe, secure location, shall be up to date and accurate at all times, and shall be available for review upon request of the Department without undue delay. LPA observed records to be locked in a closet and available for review.

LPA is requesting the following no later than 5:00PM on 11/14/25:
• updated LIC 9020 register of facility clients/residents
•LIC 500 personnel for November
•Current LIC 308 (The responsible designated substitute shall have qualifications adequate to be responsible and accountable for management and administration of the facility).
•809 Plan of Corrections listed on 809-D

As a result of this quarterly visit, LPA observed facility is not operating in full compliance with the regulations and statues governing the operation of a residential care facility for the elderly; The facility is not in compliance with Title 22 Regulations. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 04:20 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 11/05/2025 at 03:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRIENDLY ISLAND HOME
FACILITY NUMBER: 342701289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2025
Section Cited
CCR
87468.1(a)(1)

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7468.1 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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee will submit a plan to ensure there is sufficient staffing who is able to provide the services necessary to meet resident needs at all times, a daily changing log is be mantianed for residents, and a mobility device is closely available to non-ambulatory residents. Licensee will also ensure an updated LIC 602
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requirement was not met as evidence by observation, interviews, and record review in which resident 1 (R1) needs a two person assist to be repositioned and is not able to turn or reposition on their own even though they are listed as non-ambulatory on the LIC 602. Additionally, there was no mobility device available to R1 within reach. This poses an immediate health and safety risk to residents in care.
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evaluation request/ re-appraisal is completed for resident 1 (R1) by POC due date.

LPA observed staff changed R1 and placed a wheelchair near R1 during this visit.

Type B
11/14/2025
Section Cited
CCR87412(c)

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87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
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Licensee agrees to submit personnel records verification of all staff completion or enrollment for the required staff training and orientation, including (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours
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 This requirement was not met as evidence by S1-S3 not having any training verification available for review on 11/5/25. This poses a potential health and safety risk to residents in care.
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of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia, and eight hours of in-service training per year on the subject of serving residents with dementia by 11/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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