342701289-3-6-2026-27-AS-CTAO-DRWSZ8-20260306131843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 03/06/2026
Date Signed: 03/06/2026 01:18:55 PM

Document Has Been Signed on 03/06/2026 01:18 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 HOME		FACILITY NUMBER:	342701289
ADMINISTRATOR/ DIRECTOR:	MATAELE, MOLINI		FACILITY TYPE:	740
ADDRESS:	9145 ROTHSAY WAY		TELEPHONE:	(916) 670-0489
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6		CENSUS: 3	DATE:	03/06/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:02 AM
MET WITH:	Molini Mataele		TIME VISIT/ INSPECTION COMPLETED:	11:20 AM

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 3/6/26, 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(S2) and explained the purpose of the visit. S1 contacted Administrator, Molini Mataele (S1), to let them know LPA was at the facility. S1 arrived to the facility shortly after. 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. The current census is three (3) 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 3 and 2 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 last in house training were conducted 10/2025. S1 stated additional continuous training will scheduled this upcoming month and verification of training's will be kept. LPA interviewed two staff members and 2 residents. LPA provided guidance on training's and activities including Dementia Training. S1 stated residents are not too interested in activities at this time but will start to offer and encourage additional activities such as walking around in the community, movie nights, painting, games, arts and crafts. Licensee agrees to conduct fire-drills quarterly, at each shift and to practice using alternating exits. 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: 03/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

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: 03/06/2026

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Administrator and S1 have a current certificate of 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 reviewed the resident records for two new residents Resident 2 (R2) and Resident 3 (R3) did not have a Identification/emergency sheet (LIC 501) and R2 did not have an appraisal. S1 updated these documents as well as the LIC 9020 during this visit. An updated LIC 500 was requested. Administrator certificate for (S1) # 7000025740 is current and expires 09/15/2027.

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.

Per California Code of Regulations, Title 22 there were no deficiencies cited during on this 809 inspection report. A separate LIC 809 can be found on 1- year annual inspection conducted on this day. An exit interview was conducted, and a copy of this report was left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

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