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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600197
Report Date: 08/06/2025
Date Signed: 08/06/2025 01:11:29 PM

Document Has Been Signed on 08/06/2025 01:11 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FRIENDLY ACRES ELDERLY HOMEFACILITY NUMBER:
415600197
ADMINISTRATOR/
DIRECTOR:		FRANCO, KALAITA TAVAKEFACILITY TYPE:
740
ADDRESS:3526 PAGE STREETTELEPHONE:
(650) 369-4503
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 6CENSUS: 4DATE:
08/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator, Kalaita FrancoTIME VISIT/
INSPECTION COMPLETED:
01:24 PM
NARRATIVE
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On August 6, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Administrator, Kalaita Franco and Caregiver, Michael Alvis and explained the purpose of the visit.

LPAs toured the physical plant. The facility is a single story with three resident bedrooms; two private rooms and one shared room, and one staff room. There are two full bathrooms observed. Common areas observed had dirt on the floor, spider webs on the walls, and ants were observed throughout the facility.

All bedrooms had sufficient furniture, lighting, and ventilation. No accessible bodies of water or other hazards were observed. The smoke and carbon monoxide detectors were operational. The fire extinguisher was fully charged. The hot water was measured at 123-127 degrees F. A comfortable temperature is maintained.

Resident files and two staff records were reviewed. Staff records did not have required trainings. Resident files were not current and complete. The medication logs are accurate and up to date. Kitchen faucet was observed not on good working condition. 2-days perishables and 7-day non-perishables were present.

Staff did not have CPR and administrator does not have her administrator license. A civil penalty of $250 is being issued today for not having CPR as this same citation was issued within 12 months. Sharps, chemicals, and medications were all unlocked and accessible to residents in care.

Deficiencies are cited under the California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.


This report was reviewed with the caregiver and a copy of the report along with appeal rights left at the facility.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Charitra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
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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Document Has Been Signed on 08/06/2025 01:11 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/06/2025 at 12:15 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME
FACILITY NUMBER: 415600197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed chemicals and sharps unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Caregiver immediately locked the sharps and chemicals in LPAs prescense. Administrator shall ensure all chemicals and sharps are locked at all times.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 2/2 of the staff did not have CPR training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Licensee/Administrator and caregiver shall enroll in CPR training class and provide LPA a copy of enrollement. Once completed, Licensee/Administrator shall submit a copy of CPR completion.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/06/2025 01:11 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/06/2025 at 12:15 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME
FACILITY NUMBER: 415600197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed webs on the walls and furniture, observed dirt on the carpet, observed the kitchen faucet not in good working condition, observed the hallway light not working, and observed ants in the bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Licensee/ Administrator shall submit a plan in writing on how to ensure the dirt on the floor and webs on the walls will be cleaned, this plan shall include increase of hosuekeeping. Licensee/Administrator shall submit a photo to LPA of working kitchen faucet and the hallway light to be working. Licensee/administrator shall reach out to third-party vendor to treat the ants
Type A
Section Cited
HSC
1569.626(a)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the administrator or caregiver were unable to provide any training records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Licensee/Administrator and the caregiver shall ensure the training requirements are met and provided to LPA. Licensee/administrator shall do training with caregiver and ensure that documentation is remained in personnel files.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2025 01:11 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/06/2025 at 12:15 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME
FACILITY NUMBER: 415600197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed medication cabinet to be unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Caregiver immediately locked medication in LPAs presence. Licensee/administrator shall ensure all medications are locked at all times
Type A
Section Cited
CCR
87405(a)
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, there is no qualified and currently certified administrator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Licensee/administrator shall apply for administrator re-certification and provide LPA proof
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/06/2025 01:11 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/06/2025 at 12:15 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME
FACILITY NUMBER: 415600197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed ants on the kitchen floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Licensee/administrator shall reach out to third-party vendor to treat the ant. A proof of email shall be submitted to LPA with a plan for treatment
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, resident records were not complete and current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Licensee/administrator shall audit all resident files and ensure all resident files are complete and current.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 08/06/2025 01:11 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/06/2025 at 12:15 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME
FACILITY NUMBER: 415600197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, facility has not been conducting emergency drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Licensee/administrator shall conduct an emergency drill by 8/13/25 and provide LPA proof of completion. Licensee/administrator shall also submit a plan on how to ensure drills are being conducted quarterly.
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, water temperature throughout the facility was between 123-127 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Licensee/administrator to adjust water heater and provide LPA photos/videos of water temperature throughout the facility to be between 105-120 degrees F
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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