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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:06:54 PM

Document Has Been Signed on 10/02/2024 02:06 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: 3DATE:
10/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:MATAELE, MOLINITIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kesha Lewis and Charlie Yang arrived at the facility unannounced for the purpose of a health and safety check following an unlicensed complaint at the licensees home that is next door to the facility. LPA explained purpose of visit to the to staff.


Based on observations, and interview the licensee moved a resident from the licensed facility to their personal home. Based on observations LPA Lewis and Yang saw two beds in the facility that had full bed rails. The licensee has two residents that have hospital beds with full bed rails and are not on hospice. The licensee was interviewed and stated that the residents were not on hospice but that some times there feet would fall off the side so sometimes they would out just the top rail up and sometimes they put the whole rail up.

Per California Code of Regulations, Title 22 deficiencies were observed and are being cited during today's case management inspection.

An exit interview was conducted and a copy of this report and appeal rights was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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Document Has Been Signed on 10/02/2024 02:06 PM - It Cannot Be Edited


Created By: Kesha Lewis On 10/02/2024 at 01:14 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: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
87405(d)(2)

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87405 Administrator - Qualifications and Duties. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement is not meet as evidenced by:
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Administrator agrees to take training including but not limited to the following: Title 22 regulations, care and supervision and duties and responsibilities. Training topics and dates shall be submitted by POC due date.
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Based on observations, and interview the licensee moved a resident from the licensed facility to their personal home. therefore they not comply with the section cited above. The licensee did not ensure thay complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.
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Type A
10/03/2024
Section Cited
CCR87608(5)(a)(b)

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87608 Postural Supports(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(A)A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Licensee agrees to remove fails for the beds of both residents and send proof to LPA Lewis by POC date.
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Based on observations, and interview the licensee has 2 resident have hospital beds that have full bed rails and are not on hospice. This posed a immidate 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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