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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:19:28 PM


Document Has Been Signed on 07/23/2024 04:19 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:MATAELE, MOLINIFACILITY TYPE:
740
ADDRESS:9145 ROTHSAY WAYTELEPHONE:
(916) 670-0489
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 1DATE:
07/23/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Molini MataeleTIME COMPLETED:
04:45 PM
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On 7/23/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a post-licensing inspection. LPA met with Licensee Molini Mataele and explained the purpose of the visit.

Administrator’s certificate is current and will expire on 9/15/25. The facility is licensed for six (6) ambulatory, of which two (2) may be non-ambulatory in room 1#. Current census is 1.

LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature was measured at 110.3*F which was within the required range of 105-120*F. The temperature inside the facility was observed to be at 70*F which was within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the clients at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.

LPA reviewed (1) client files and (2) staff files, including criminal record clearances. LPA confirmed all residents’ files have required records. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Per California Code of Regulations, Title 22, there were no deficiencies cited during today's inspection. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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