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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701289
Report Date: 08/12/2025
Date Signed: 08/12/2025 04:26:45 PM

Document Has Been Signed on 08/12/2025 04:26 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/
DIRECTOR:		MATAELE, MOLINIFACILITY TYPE:
740
ADDRESS:9145 ROTHSAY WAYTELEPHONE:
(916) 670-0489
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 3DATE:
08/12/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 PM
MET WITH:Griselda MartinezTIME VISIT/
INSPECTION COMPLETED:
04:56 PM
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On 8/11/2025, 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(S1) and explained the purpose of the visit. S1 contacted Administrator Molini Mataele to let them know LPA was at the facility.

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. Current census is 3 residents. 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. There is 1 staff present. All staff are criminal background cleared. Administrator certificate is 600674740 and is valid until 9/15/2025.

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.

2. Maintain current, personnel records of each employee at the facility and ensure all employees 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.

4. Maintain an accurate, complete, and current client roster which must be made available to the Department upon review.

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: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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: 08/12/2025
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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.

Licensee has completed working with the Technical Support Program (TSP) on 8/1/2025 in which they received assistance/resources regarding record keeping, personnel training, and Administrator qualifications. A review of the TSP Engagement Summary has been received and placed in the facility file.

LPA observed the Stipulation Order posted in bulletin board. LPA observed records to be locked in a closet and available for review. LPA reviewed 3 resident records and 2 staff records, records are incomplete.
LPA reviewed the resident records for 3 residents Eileen Stockton (R1),Thomas Velarde (R2), and Margaret Searcy (R3). Records were missing an LIC 627C consent form for R1-R3. R3 is also missing an 602/physician’s report (has not received one from kaiser) for Administrator stated they have requested the form from Kaiser but its still pending, as they have not given it back to them. LPA reviewed the Medication Administration Records (MARS) for 3 residents (R1-R3) and observed signatures were missing for evening medications on 8/11/25 for all residents. LPA contacted Administrator via phone call and they informed they were “at work” and stated medications were administered 8/11/2025 but they “forgot to sign”. Administrator stated in house training have been provided for staff but they do not have verification available at this time. LIC 9020 register of facility clients/residents was observed listing 2 out of 3 resdients, a current version of LIC 9020 register of facility clients/residents was requested.

LPA requested to review personnel records of each employee at the facility. Administrator and S1 has a current certificate of CPR and first aid training on file at the facility. There is no record available for review for staff, Lucaria Contreras (S3). S2 and S3 have criminal background clearance. Administrator stated S3 has not completed CPR or TB test clearance. Administrator agreed S3 will not to work at the facility until they complete TB test and required training's. 3 out of 3 staff records (administrator, S1, S2) are missing training verifications for medication administration and records keeping, dementia, and techniques of personal care services as specified in Health and Safety Code sections 1569.625 and 1569.69.

LPA is requesting the following by 08/18/25 5:00PM
• LIC 9020 register of facility clients/residents

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: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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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: 08/12/2025
NARRATIVE
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•LIC 500, personnel
• CPR certification for Lucaria Contreras
•TB clearance for Lucaria Contreras
• LIC 627C consent form for all residents

As a result of this quarterly visit,LPA observed facility is not operating in full compliance with the regulations and statues governing the operation of a residential care facility for the elderly; The facility is not in compliance with Title 22 Regulations. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2025 04:26 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 08/12/2025 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRIENDLY ISLAND HOME
FACILITY NUMBER: 342701289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2025
Section Cited
CCR
87465(a)(6)

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87465 Incidental Medical and Dental Care (a) A plan for ... routine medical and dental care (6) When requested by ... the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement was not met as evidenced by:
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Licensee to ensure to complete accurate Medication administration records for all residents. Licensee will complete an all staff training on medication administration and documentation. Proof of completed training to be submitted to LPA by POC due date.
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Medication administration record not being signed off for administered medications
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Type B
08/18/2025
Section Cited
CCR87412(c)

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87412 Personnel Requirements - General
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
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Licensee to ensure completed staff training specified in regulation 87412 (Personnel Records) and 87411 (Personnel Requirements) is completed. Licensees will maintain in the personnel records verification of required staff training and orientation.
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 personnel records verification of required staff training and orientation verifcation were not being available for review by LPA.
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Proof of completed training to be submitted to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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