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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801929
Report Date: 06/16/2023
Date Signed: 06/16/2023 09:49:52 AM


Document Has Been Signed on 06/16/2023 09:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:FRIENDS HOUSEFACILITY NUMBER:
496801929
ADMINISTRATOR:ROBERT RUBIOFACILITY TYPE:
741
ADDRESS:684 BENICIA DRIVETELEPHONE:
(707) 538-0152
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:145CENSUS: 77DATE:
06/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Robert RubioTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Friends House for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Administrator, Robert Rubio and was granted access into the facility.

During the Case Management-Incident Inspection, LPA discussed an incident report that was forwarded to the Regional Office on June 6, 2023. LPA learned that there was an incident that occurred on February 8, 2023 regarding a fall and the resident denying medical treatment (See LIC 9102-Technical Violation). However, during a routine doctors check-up, the resident had a cat scan on June 2, 2023 that determined a mild fracture. LPA and Administrator discussed California Code of Regulation #87211-Reporting Requirements and the importance of submitting incident reports in a timely manner.

LPA toured the facility with the Administrator and found the facility to be clean and at a comfortable temperature with all exits free from obstruction. LPA observed construction that is being conducted on the facility grounds. LPA requested the following documents to be sent:

-Letterhead indicating what the alteration is for
-Building Permits (IF ANY)

No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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