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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701289
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:17:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240715120959
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
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Molini Mataele - LicenseeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility accepted resident without authorization
Staff did not provide resident's records to their responsible party as necessary
Wrongful Eviction
INVESTIGATION FINDINGS:
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On 9/24/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to complete and delivery findings for a complaint investigation with the allegations above. LPA met with Licensee Molini Mataele and discussed the conclusion for complaint and the findings.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Regarding the allegation, “Facility accepted resident without authorization” LPA obtained the following information through interviews. It was learned that the facility admitted resident #1 (R1) without R1’s Power of Attorney (POA) consent and agreement. R1 was admitted on 6/1/2024. It wasn’t until 7/2/2024 that R1’s responsible party was contacted to do admission paperwork.

Regarding the allegation, “Staff did not provide resident’s records to their responsible party as necessary” LPA obtained the following information through interviews. It was learned that the facility did not provide R1’s responsible party with proper admission agreement upon admitting R1. Facility also did not provide proof of current liability insurance to R1’s responsible party as requested.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20240715120959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/24/2024
NARRATIVE
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Regarding the allegation, “Wrongful eviction” LPA obtained the following information through interviews. It was learned that the facility drops off R1 at the hospital due to nonpayment. The facility did not provide R1 and R1’s responsible party with a 30-day eviction notice as required by Title 22 Regulations.

As a result of the investigation, LPA finds the allegations above to be SUBSTANTIATED- A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20240715120959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87457(b)
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87457(b) Pre-admission Appraisal - No person shall be admitted without his/her consent and agreement, or that of his/her responsible person, if any.
This requirement is not met as evidenced by:
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Licensee shall review and send a statement of understanding of this regulation to CCL by the close of POC date.
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Based on records review and interviews, the licensee admitted R1 without R1’s responsible party consent and agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
10/08/2024
Section Cited
CCR
87507(c)
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87507(c) Admission Agreements. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission.
This requirement is not met as evidenced by:
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Licensee shall review and send a statement of understanding of this regulation to CCL by the close of POC date.
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Based on records review and interviews, the licensee did not provide the resident’s representative the admission agreement following admission which poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240715120959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87224(a)
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87224(a) Eviction Procedures: the licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...
This requirement is not met as evidenced by:
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Licensee shall review and send a statement of understanding of this regulation to CCL by the close of POC date.
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Based on file review and interviews, the Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice. This posed a potential health and safety risk to R1.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4