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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 09/24/2024
Date Signed: 09/24/2024 11:25:41 AM


Document Has Been Signed on 09/24/2024 11:25 AM - 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: 3DATE:
09/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Molini Mataele - LicenseeTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit on 9/24/24. LPA met with Licensee Molini Mataele and explained the purpose of today’s visit.

The purpose of the visit is to follow up on deficiencies learned during complaint investigation, COMPLAINT CONTROL NUMBER: 27-AS-20240715120959. Through the complaint investigation, it was learned that the licensee admitted resident (R1) without R1’s responsible party consent and agreement. It was also learned that the licensee did not provide the resident’s representative the admission agreement within 7 days following admission. In addition, it was learned that the licensee did not follow eviction procedures outlined in Title 22 Regulations. The Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice.

As a result, the following deficiency was cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency can be found on the 809-D page.



Exit interview was conducted, and a copy of this report, 809-D, and appeal rights given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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 09/24/2024 11:25 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2024
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 in-service training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC due date.
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Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee 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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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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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