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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:24:18 PM


Document Has Been Signed on 11/09/2023 03:24 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 HOMEFACILITY NUMBER:
342701289
ADMINISTRATOR:MATAELE, MOLINIFACILITY TYPE:
740
ADDRESS:9145 ROTHSAY WAYTELEPHONE:
(916) 670-0489
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 1DATE:
11/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Molini MataeleTIME COMPLETED:
03:45 PM
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On 11/9/23, 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 Truong met with Applicant Molini Mataele, who assisted LPA Truong in today’s inspection.

LPA Truong toured the facility with Applicant Molini Mataele. There was 1 resident in care currently. LPA reviewed resident's file. During today's visit, all corrections were completed, and the applicant has passed the pre-licensing visit.

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

Pre-Licensing is complete, and this facility has no deficiencies. A Component III was completed at this time with the applicant. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

An exit interview was conducted, and a copy of this report was given to the applicant.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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