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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201172
Report Date: 06/30/2023
Date Signed: 06/30/2023 02:54:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230228130610
FACILITY NAME:FRIENDSHIP CARE HOMEFACILITY NUMBER:
079201172
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:35CENSUS: 31DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not safeguard resident’s belongings
INVESTIGATION FINDINGS:
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On 06/30/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Staff did not safeguard resident’s belongings
Investigation Finding: Substantiated
During investigation, staff (ADM) confirmed with LPA that some of resident’s (R1) personal belongings were missing in her room when family member collected R1’s belongings after R1 passed away on 01/12/23.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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 7
Control Number 15-AS-20230228130610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
VISIT DATE: 06/30/2023
NARRATIVE
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ADM stated they later contacted authorized representative (POA) several times to pick up R1’s remaining misplaced personal items (wall décor wreath, Black IPad and photo album) left at the facility with no response from POA. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not safeguard R1’s belongings was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20230228130610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87217(b)
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Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff…
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By POC due date, Administrator agreed to complete and submit to CCL in-service staff retraining certifications on safeguarding residents' cash resources and personal belongings in compliance
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This requirement was not met as evidenced by R1's misplaced personal belongings at the facility which posed a potential health & safety risk to residents in care
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with Title 22 Section 87217.

Administrator stated POA and Ombudsman were both notified regarding R1's remaining personal belongings that need to be picked up at the facility.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230228130610

FACILITY NAME:FRIENDSHIP CARE HOMEFACILITY NUMBER:
079201172
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1907 CAVALLO ROADTELEPHONE:
(925) 732-7364
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:35CENSUS: 31DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cynthia Murphy, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident developed pressure injuries due to staff neglect
Staff did not provide adequate assistance to resident in a timely manner
Staff did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care
Staff did not communicate with resident’s representative regarding resident’s change in condition in a timely manner
Staff did not turn resident as necessary
Staff did not accord resident dignity
Staff did not maintain medical equipment in a sanitary manner
INVESTIGATION FINDINGS:
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On 06/30/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Resident developed pressure injuries due to staff neglect
Investigation Finding: Unsubstantiated
During investigation, staff (ADM) confirmed with LPA that resident (R1) was admitted into hospice care on 06/10/22. R1 was first admitted at the facility on 10/20/2020. Review of Home Health and Hospice records show that on 12/29/22, hospice nurse observed R1 had no wound, rash, ulcer/bed sores or any other skin symptoms.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20230228130610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
VISIT DATE: 06/30/2023
NARRATIVE
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Allegation: Resident developed pressure injuries due to staff neglect
Investigation Finding: Unsubstantiated
Continuation:
On 01/03/23, R1 developed a new skin issue on her right heel (stage 1) and a redness on her left heel. On 01/10/23, the right heel wound developed into a stage II/III pressure injury. Staff implemented hospice care instructions on how to offload pressure on heels. On 01/11/23, hospice care team nurse observed the right heel pressure injury was a stage 1. Blister was wrapped in a kerlix and there was redness on the left heel. No new skin issue was noted by hospice nurse. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident developed pressure injuries due to staff neglect is unsubstantiated.

Allegation: Staff did not provide adequate assistance to resident in a timely manner
Investigation Finding: Unsubstantiated
During investigation, IB Investigator confirmed with Home Health and Hospice care team that R1 was on Home Health and Hospice Care from 06/10/22 to 01/12/23. Review of hospice records show that R1 received care and supervision by hospice care team (RN, LVNs, NP) while in hospice care. Staff (ADM, S1, S2) stated they implemented R1’s hospice care plan as instructed by the hospice care team. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not provide adequate assistance to resident in a timely manner is unsubstantiated.

Allegation: Staff did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care


Investigation Finding: Unsubstantiated
During investigation, staff (ADM) stated that staff implemented hospice care instructions on how to offload pressure on R1’s heels by elevating her feet with foam or pillow supports. ADM stated that any invasive medical procedure on R1 was performed by the hospice care team only. Review of hospice records show hospice team notified and updated R1’s family / primary caregiver and primary care physician regarding R1’s condition on 12/29/22, 01/03/23, 01/10/23, 01/11/23 and 01/12/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care is unsubstantiated.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20230228130610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
VISIT DATE: 06/30/2023
NARRATIVE
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Allegation: Staff did not communicate with resident’s representative regarding resident’s change in condition in a timely manner
Investigation Finding: Unsubstantiated
During investigation, staff (ADM) confirmed with LPA that R1’s authorized representative (POA) was updated on R1’s change in condition while in hospice care. Review of hospice records show hospice care team notified and updated R1’s family / primary caregiver and primary care physician regarding R1’s condition on 12/29/22, 01/03/23, 01/10/23, 01/11/23 and 01/12/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not communicate with resident’s representative regarding resident’s change in condition in a timely manner is unsubstantiated.

Allegation: Staff did not turn resident as necessary
Investigation Finding: Unsubstantiated
During investigation, staff (S1) stated that they followed resident’s (R1) hospice care plan as instructed by the hospice nurses. Review of R1’s hospice records dated 01/11/23 show R1 had no new skin issues noted, blister on right heel (currently wrapped in kerlix) and redness on left heel. Staff (S1) stated that R1 was not on a turning scale schedule because R1 can still turn on her own. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not turn resident as necessary is unsubstantiated.

Allegation: Staff did not accord resident dignity
Investigation Finding: Unsubstantiated
During investigation, staff (ADM, S1, S2) denied verbally abusing resident (R1) while in care at the facility. LPA interviewed random residents (R2, R3, R4) who stated that staff treat them well and do not call them names. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore that staff did not accord resident dignity is unsubstantiated.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20230228130610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FRIENDSHIP CARE HOME
FACILITY NUMBER: 079201172
VISIT DATE: 06/30/2023
NARRATIVE
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Allegation: Staff did not maintain medical equipment in a sanitary manner
Investigation Finding: Unsubstantiated
During investigation, staff (ADM) confirmed with LPA that resident (R1) had dedicated use of medical equipment while in care. ADM stated that staff followed resident’s (R1) hospice care plan as instructed by the hospice nurses and sanitized medical equipment as prescribed by the hospice care team. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not maintain medical equipment in a sanitary manner is unsubstantiated.

Exit Interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7