Friendship Care Home

A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed… This requirement was not met as evidenced by facility not giving the refund to resident’s responsible party which posed a potential health & safety risk to resident in care.

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 was not met as evidenced by administrator is not at the facility a sufficient number of hours per week which posed a potential health & safety risk to residents in care.

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by facility does not have enough afternoon and night staff to meet residents’ need which posed a potential health & safety risk to residents in care.

The following space and safety provisions shall apply to all facilities: Sufficient room shall be available to accommodate persons served in comfort and safety. This requirement was not met as evidenced by facility is not equipped to serve residents in the dining areawhich posed a potential health & safety risk to residents in care.

(d)If the resident is unable to determine...all of the following requirements are met:This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.

b) The following..shall apply:(6)In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance...This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by not creating and following a weekly menu which poses a potential personal rights violation for residents in care.

(a) Except as specified.. sharp objects, and other similar items..are in locked storage ...This Requirement is not met as evidence by: Based on observation the facility did not comply with the section above by having unlocked and accessible scissors which pose an immediate personal rights violation safety risk for residents in care.

(a)Facility personnel shall at all times be sufficient in numbers... to meet resident needs...This requirement is not met as evidence by: Based on observation and conversation the facility did not comply with the section above by not having a sufficient number of staff to meet the residents needs which poses a potetional personal rights violation for residents in care.

(d)If the resident is unable to determine...all of the following requirements are met:This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.

(b) The following..shall apply:(9)Procedures.. of food shall be observed in food storage...This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by not storing food properly which poses a potential health violation for residents in care.

(b) The following..shall apply:(8) All food shall be of good quality...This requirement is not met as evidence by: Based on observation the facility did not comply with the section above having expired food which poses a potential health and personal rights violation for residents in care.

(b) Each resident’s record shall contain at least the following information:This requirement is not met as evidence by: Based on record review the facility did not comply with the section above by having incomplete resident records which poses a potential personal rights violation for residents in care.

(b) The following..shall apply:(6)In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance...This requirement i not met as evidence by: Based on observation the facility did not comply with the section above by not creating and following a weekly menu which poses a potential personal rights violation for residents in care.

(a) Based on the individual's preadmission appraisal...Postural supports may be used under the following conditionsThis Requirement is not met as evidence by: Based on observation and file review the facility did not comply with the section above by R1 and R2 utilizing postural supports that are not documented in their file and do not have spring releases which pose an immediate personal rights violation for residents in care.

(c)Licensees shall prominently post(2)Information...shall be posted as follows:(A) Licensees may use...PUB 475. The poster that is posted shall be 20" x 26" in size...This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by PUB 475 poster being the incorrect dimensions and too small which poses a potential personal rights violation for residents in care.

(a) The facility shall be clean...(1) Floor surfaces in ... kitchen areas...This requirement i not met as evidence by: Based on observation the facility did not comply with the section above by kitchen floors being dirty which poses a potential health risk for residents in care.

(a) Living...shall be large enough...The following provisions shall apply:(1) There shall be...dining rooms...shall be of sufficient...from interfering with other functions.This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by placing residents in the walkways to eat because the dining area is insufficient which poses a potential personal rights violation for residents in care.

(a) Except as specified...the licensee shall ensure that disinfectants... are in locked storage... Based on observation the facility did not comply with the section above by having room with disinfectent unlocked and kitchen unsecured which poses an immediete safety violation for residents in care.

The facility shall ... in good repair at all times...This requirement is not met as evidenced by: Based on observation the facility did not comply with the section above by having multiple broken locks and door which poses a potential personal rights violation for residents in care.

(a) Residents in all residential care... shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building....This requirement is not met as evidenced by: Based on observation the , Licensee did not comply with the regulation cited above by locking front main entrance door with a key and having child locks on perimeter doors which poses an immediate personal rights violation to persons in care.

All facilities shall be maintained in...regulations adopted by the State Fire Marshal...This requirement was not met as evidence by Based on observation the facility did not comply with the section above by having multiple fire exits blocked which poses an immediete safety violation for residents in care.

Based on observation, the licensee did not comply with the section cited above as evidenced by open and disorganized residents & staff office documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as evidenced by water leak causing floor to buckle & develop mold which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interviews, the licensee did not comply with the section cited above as evidenced by common hallway flooring needing repairs which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as evidenced by a large hole in the backyard asphalt driveway which poses/posed a potential health, safety or personal rights risk to persons in care.

The executor or the administrator of the estate shall be notified by the licensee, and the cash resources, personal property, and valuables surrendered to said party. This requirement was not met as evidenced by staff withholding resident’s personal belongings to authorized representative on 11/01/23.

Facility staff did not comply with Section 87303 (a):The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by broken gate, kitchen vents and damaged shower walls and flooring which posed a potential health & safety risk to residents in care.

Facility staff did not comply with Section 87555 (a): The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by insufficient 2 day perishable food supply which posed a potential health and safety risk to residents in care.

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… 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

All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by facility not providing authorized representative a copy of resident's records which posed a potential health & safety risk to resident in care.

Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652 This requirement was not met as evidenced by late refund of R1's paid September 2022 when R1 passed away on 09/26/22 which was in violation of Title 22 Section 87507 refund regulation.

87211(a)(1) REPORTING REQUIREMENTS(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above by not submitted an incident report for R1 which poses a potential heatlh and safety risk to residents in care.

87507(g)(5)(A) ADMISSION AGREEMENT(5) Refund conditions.(A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement is not met as evidenced by: Based on record review and interview, the Licensee did not comply with the regulation cited above by stating there is a non-refundable policy which poses a potential personal rights to persons in care.

87568.1(a)(6) PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building.... This requirement is not met as evidenced by: Based on observation and interviews, Licensee did not comply with the regulation cited above by locking front main etrance door with a key which poses an immediate personal rights to persons in care.

87307(d)(6) PERSONAL ACCOMODATIONS AND SERVICES(d)The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above by storing items blocking the exit doors which poses a potential health and safety risk to persons in care.

87405(d)(2) ADMINISTRATOR - QUALIFICATIONS AND DUTIES(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above by visitor was not screened and requested to sign in which poses a potential health and safety risk to persons in care.

Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate This requirement was not met as evidenced by absence of LIC 624 on incident which posed a potential health & safety risk to residents in care

Personnel RequirementsFacility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by insufficient staff to meet residents' needs which posed an immediate health & safety risk to residents in care

Maintenance & OperationThe facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by deteriorating floorings, warm temperature and broken window blinds which posed a potential health & safety risk to residents in care

General food service requirementsThe total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by insufficient perishable and non perishable food in the kitchen pantry which posed an immediate health & safety risk to residents in care