Friendly Island Home

Type of visit: Case Management - Deficiencies

On 5/7/26 at 9:00am, Licensing Program Analyst (LPA) Kevin Gould Conducted a case management deficiencies inspection to address deficiencies observed during an unrelated complaint investigation. LPA observed one of the staff member present has a criminal record exemption denial issued by the department on 1/18/26. LPA observed the lock on the drawer for sharp knives is broken and the items are not stored in a manner that is inaccessible to residents in care. Additionally, LPA observed other items such as a saw left in the back yard left on a chair and accessible to residents in care. LPA also observed a large table on it side blocking the side emergency exit of the facility from the back to front yards. LPA observed ants on the kitchen table and live cockroaches in a trap in the kitchen. Staff member present stated there are no current pest control companies providing services to the facility at this time. The following deficiencies are cited per the California Code of Regulations, Title 22. An immediate civil penalty was issued as a result of the identified deficiencies. Exit interview conducted and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, May 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b)(1)(D) · Plan of correction due date: May 8, 2026

Criminal Record Clearance: In addition to the applicant, the provisions of this section shall apply to criminal convictions of the following persons: any staff person, volunteer, or employee who has contact with the clients. This requirement was not met as evidenced by LPA review of staff criminal record clearance and one staff member does not have a criminal record clearance as their exemption was denied by the department and poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Facility will either terminate staff member or contact Care Provider Management Bureau to obtain a criminal record exemption. Facility has agreed to provide a statement in writing that the staff member will not be present at the facility until their exemption is approved. If denied they will terminate staff member.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 8, 2026

Storage Space and Access: 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 was not met as evidenced by LPA observations of sharp knives and saw stored accessible to clients in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: LPA observed all sharp knives relocated to a secured closet in the hallway by the living room where mediations are stored. facility agrees to repair the lock in the kitchen drawer to ensure knives are safety stored and will ensure all items are stored in the garage and all garage doors will be locked at all time.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: May 8, 2026

Personal Accommodations and Services: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by LPA observations of a large wood table on its side blocking the exterior emergency exit to the front of the home which poses an Immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Licensee will remove all furniture and items not for resident use and will provide a written statement of understanding that no items or furniture should be blocking any emergency exit or passageways inside and outside of the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(27) · Plan of correction due date: May 15, 2026

General Food Service Requirements: All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by LPA observations of live ants and cockroaches present in the facility kitchen upon arrival wich poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Facility has agreed to contact pest control and schedule a service by 5/8/26. Facility will send a copy of the service report to the department by 5/15/26.

Type of visit: Case Management - Other

On 3/6/26, 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(S2) and explained the purpose of the visit. S1 contacted Administrator, Molini Mataele (S1), to let them know LPA was at the facility. S1 arrived to the facility shortly after. An entrance interview was conducted. 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. The current census is three (3) resident. 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. The census is 3 and 2 staff. All staff are criminal background cleared. 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. LPA observed the facility is not in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly. LPA observed last in house training were conducted 10/2025. S1 stated additional continuous training will scheduled this upcoming month and verification of training's will be kept. LPA interviewed two staff members and 2 residents. LPA provided guidance on training's and activities including Dementia Training. S1 stated residents are not too interested in activities at this time but will start to offer and encourage additional activities such as walking around in the community, movie nights, painting, games, arts and crafts. Licensee agrees to conduct fire-drills quarterly, at each shift and to practice using alternating exits. Continued on 809-C Administrator and S1 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. LPA observed the Stipulation Order posted in bulletin board in a common area. 4. Maintain an accurate, complete, and current client roster which must be made available to the Department upon review. LPA reviewed the resident records for two new residents Resident 2 (R2) and Resident 3 (R3) did not have a Identification/emergency sheet (LIC 501) and R2 did not have an appraisal. S1 updated these documents as well as the LIC 9020 during this visit. An updated LIC 500 was requested. Administrator certificate for (S1) # 7000025740 is current and expires 09/15/2027. 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. LPA observed records to be locked in a closet and available for review. Per California Code of Regulations, Title 22 there were no deficiencies cited during on this 809 inspection report. A separate LIC 809 can be found on 1- year annual inspection conducted on this day. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 6, 2026

Type of visit: Required - 1 Year

On 3/6/26, 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 (S2) and explained the purpose of the visit. S1 contacted Administrator, Molini Mataele (S1), to let them know LPA was at the facility. S1 arrived to the facility shortly after. An entrance interview was conducted. Friendly island home is residential care elderly (RCFE) and it is licensed to serve 6 elderly adults with age range 60 and over. The facility is approved for six (6) ambulatory, of which two (2) may be non-ambulatory in room 1. Hospice waiver approved for 1. This facility is on probation until 02/05/2027. A separate case management quarterly inspection was conducted on this day. LPA toured the facility with S1, and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 99 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. Two resident restroom faucets and one kitchen faucet were tested by LPA which measured 98.8 degrees F. Licensee adjusted water heater to ensure water temperature is within regulation. LPA Tamayo observed first aid supplies, there was a fully- charged and up-to-date fire extinguisher, and functioning carbon monoxide/smoke detectors that are tested periodically. The facility is conducting quarterly emergency drills and ensuing to use alternating exits during simulations. LPA Tamayo observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA observed a locked cabinet for the storage of medication. LPA provided additional guidance regarding 7 day supply of non-perishable foods; 3 meals a day per resident in care for 7 days is approximately 63 meals should be at the premises at all times. LPA Tamayo observed locked cabinets for the storage of cleaning solutions and knives. Continued on 809-C The exterior of the building was inspected: There were no outbuildings or bodies of water present and the yard was completely fenced in. There was also a sitting area for residents in the backyard. Administrator certificate # 7000025740 and expires 09/15/2027. S1 attended Dementia training on 7/2025 and provided training to care staff (S1). LPA compared the LIC 500 with the roster of staff obtained from Guardian to ensure that all staff had the appropriate background clearances to be working with the residents in care. All were in compliance at the time of this inspection. LPA interviewed two staff members and 2 residents. LPA provided guidance on training's and activities including Dementia Training. S1 stated residents are not too intrested in activities at this time but will start to offer and encourage additional activities such as walking around in the community, movie nights, painting, games, arts and crafts. LPA requested the following documents to be sent to cynthia.tamayo@dss.ca.gov by end of day 3/12/26 LIC 308: Designation of Administrative Responsibility listing all Designated individuals and their contact information LIC 402: Surety Bond, if applicable LIC 610E: current Emergency Disaster Plan Copy of current Liability Insurance Licensee shall pay annual licensing fees by due date. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and an exit interview conducted.the state’s words, verbatim · CDSS document, Mar 6, 2026

The state marks this report as 10 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

On 11/5/25, 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 (FDA) to let them know LPA was at the facility but they did not answer. FDA called LPA back at 11:30 AM but did not respond to phone calls at 12:09 and 3:38 PM. An entrance interview was conducted. 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 one (1) resident. 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. The census is 1 and 1 staff. All staff are criminal background cleared. 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. LPA observed the facility is not in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly. LPA observed the facility was not free from odors and there was evidence of an existing mouse and/or insect problem in the kitchen. LPA observed S1 take out the trash at 3:55PM. LPA observed a pile of dirty clothes in R1's bathroom; Staff reported the washing machine stopped working about 2-3 weeks ago and they tried to have someone repair it two weeks ago but were unsuccessful. Both machines were removed due to it not working and a new washing machine and dryer machine will be installed. FDA stated laundry is being completed off-site until a replacement is completed. A new LIC 602 evaluation will be requested from R1's physician due to them not being able to reposition on their bed. Continued on 809-C LPA observed there was no mobility device placed was within accessible distance from R1. LPA observed staff place a wheelchair near R1 during this visit. LPA also observed S1 feed lunch to R1 from 12:00PM -12:30PM. LPA observed one changing took place fro R1 during this visit. 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. LPA reviewed three staff records, all staff has a current 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. LPA observed the Stipulation Order posted in bulletin board in a common area. 4. Maintain an accurate, complete, and current client roster which must be made available to the Department upon review. LPA observed the most current roster is dated 8/16/2025 and needs to be updated due to two out of three residents are no longer living in the facility. LPA reviewed the resident records for Resident 1 (R1) in which the completed 627C consent form was still not added to the resident's file. LPA reviewed the Medication Administration Records (MARS) for one resident (R1) and observed FDA did not complete the MARS on 11/3/25. LIC 9020 register of facility clients/residents dated 8/16/25, lists two former residents, a current version of LIC 9020 was requested. LIC 500 Personnel Record dated 8/16/25, lists is not up to date, an updated LIC 500 was requested. LPA requested to review personnel records of each employee at the facility. Administrator, S1, and S3 have a current certificate of CPR and first aid training on file at the facility. There is no training verification for any resident available for review. LPA observed Administrator certificate # 600674740 and expired 9/15/202 and there is not verification of an updated administrator certificate is in processes. FDA stated they paid the renewal fee and submitted the hours verification for the Administrator certificate renewal via the online portal, however they are not able to provide any verification at this time due to being at work. Continued on 809-C 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. LPA observed records to be locked in a closet and available for review. LPA is requesting the following no later than 5:00PM on 11/14/25: • updated LIC 9020 register of facility clients/residents •LIC 500 personnel for November •Current LIC 308 (The responsible designated substitute shall have qualifications adequate to be responsible and accountable for management and administration of the facility). •809 Plan of Corrections listed on 809-D 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.the state’s words, verbatim · CDSS document, Nov 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 14, 2025

87405 Administrator - Qualifications and Duties (a) ... shall have a qualified and currently certified administrator ... administrator shall have .... freedom from other responsibilities ... on the premises a sufficient number of hours to permit adequate attention to the management and administration ... This requirement was not met as evidence by record review in which there is no current administrator cerificate for Molini Mateaele (FDA). Additionally, LPA observed FDA was not avaialble in person nor via immidiate phone call on 8/12/25 and 11/5/25. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Licensee will submit valid administrator certificate for the designated administrator by 11/14/25. Licensee will also submit a plan to ensure compliance with 87405(a); in which the designated qualified administrator has freedom from other responsibilities and is on the premises a sufficient number of hours to permit adequate attention to the management and administration.

From the deficiency page — Deficiency type: Type B · Section cited: CCR888(b)(27) · Plan of correction due date: Nov 14, 2025

87555 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 was not met as evidence by interviews and observations. LPA observed there are mouse traps and pantry moths in the pantry. FDA stated mice have came in the home "from the outside". This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Licensee will submit a plan to ensure the kitchen area to ensure it is sanitary and free of litter, rodents, vermin and insects, including ensure food storage areas and all food items are inspected before storing by 11/14/25. Licensee will also schedule pest control services to evaluate the facility for services by 11/14/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 6, 2025

7468.1 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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. requirement was not met as evidence by observation, interviews, and record review in which resident 1 (R1) needs a two person assist to be repositioned and is not able to turn or reposition on their own even though they are listed as non-ambulatory on the LIC 602. Additionally, there was no mobility device available to R1 within reach. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Licensee will submit a plan to ensure there is sufficient staffing who is able to provide the services necessary to meet resident needs at all times, a daily changing log is be mantianed for residents, and a mobility device is closely available to non-ambulatory residents. Licensee will also ensure an updated LIC 602 evaluation request/ re-appraisal is completed for resident 1 (R1) by POC due date. LPA observed staff changed R1 and placed a wheelchair near R1 during this visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(c) · Plan of correction due date: Nov 14, 2025

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement was not met as evidence by S1-S3 not having any training verification available for review on 11/5/25. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Licensee agrees to submit personnel records verification of all staff completion or enrollment for the required staff training and orientation, including (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia, and eight hours of in-service training per year on the subject of serving residents with dementia by 11/14/25.

Type of visit: Case Management - Legal/Non-compliance

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 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 •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.the state’s words, verbatim · CDSS document, Aug 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Aug 18, 2025

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: Medication administration record not being signed off for administered medicationsthe state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(c) · Plan of correction due date: Aug 18, 2025

87412 Personnel Requirements - General (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. personnel records verification of required staff training and orientation verifcation were not being available for review by LPA.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: 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. Proof of completed training to be submitted to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Tamayo arrived at facility unannounced to conduct a quarterly visit on 5/22/2025, LPA Cynthia Tamayo met with administrator Molini Mataele and explained the purpose of the visit. Administrator certificate is 600674740 and is valid until 9/15/2025. The purpose of the visit today is to conduct a quarterly visit. Current census is 2 residents, one ambulatory and one non-ambulatory. LPA toured 3 private resident bedrooms. All rooms were observed to meet the resident's needs at this time. Living area, dining area and other resident areas were observed. Furniture was observed to be in good repair. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food supply at this time. Indoor temperature of the facility was 75 * F. Bathroom faucet is in disrepair. Licensee said they haven not had time to get it fixed but will schedule a repair technician this week. The bathroom shower did not have a non-slip mat area and stated a new one will be purchased by 5/23/25. Licensee demonstrated the cabinets in the bathroom, kitchen, and laundry room lock via magnetic mechanism to ensure toxins are locked and inaccessible to residents. 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: Licensee stated she understands staff/volunteers to be criminal background cleared and TB tested before entering into the facility again. Licensee scheduled Griselda and husband, Shumway Matele for a finger print clearance appointment. Licensee has initiated Technical Support Program (TSP) and is scheduled to meet with TSP representative May 28, 2025 at 1:30 PM. Continued on 809-C 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: LPA Tamayo reviewed 3 staff files and they were complete, Missing signature on LIC 501 will be completed. All staff have current CPR certification. Licensee missed Dementia training scheduled for 5/28/25-5/29/25 due to not having coverage and rescheduled for a virtual training on 7/1/25-7/2/25, verification provided. LPA Tamayo reviewed 2 staff files and it was complete and the staff had current CPR certification. 3. Post the Stipulation in a conspicuous place at the facility for the duration of the probationary period: Facility is in compliance and has Stipulation posted in bulletin board. 4. Maintain an accurate, complete, and current client roster which must be made available to the Department upon review: Facility is in compliance. Consent form is pending completion, Licensee will work on maintenance of record with TSP. 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: Records are locked in a closet and available for review. As a result of this quarterly visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. 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.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)5 · Plan of correction due date: May 23, 2025

87303 Maintenance and Operation (e) Water ... fixtures shall be maintained as follows...(5)Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement was not met as evidenced by: Licensee did not ensure to have ) Slip-resistant mats, strips, or flooring shall be used in resident bathtub which poses a potential health, safety risk to residents in carethe state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee will buy a bathmat for resident bathroom by 5/23/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80087(e)6 · Plan of correction due date: May 23, 2025

87303 Maintenance and Operation (e) Water ...fixtures.. shall be maintained as follows ... 6)... hand washing ... facilities shall be maintained in operating condition... This requirement was not met as evidenced by: Licensee did not ensure to have a repaired bathroom which poses a potential health, safety risk to residents in carethe state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee schedule a technician to repair the resident bathroom faucet by 5/23/2025.

Type of visit: Required - 1 Year

On April 3, 2025 at 1:00 PM Licensing Program Analyst (LPA) Cynthia Tamayo and Licensing Program Manager (LPM) Czarrina Camilon-Lee arrived at Friendly Island Home for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Molini Mataele and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor. LPA observed that all rooms are equipped with the required furniture throughout the facility. LPA measured the water temperature, temperature measured at 111.3 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 627-C Consent formsLIC 999 Facility Sketch, LIC 9020 client roster and current administrator certificate. Per California Code of Regulations, Title 22 there were deficiencies cited during today's inspection, see 809-D. Appeal Rights provided. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Office

An virtual office meeting was conducted on today's date via Microsoft Teams to discuss the Stipulation and Waiver; and Order that went into effect February 5th, 2025. Present in today's meeting was Sacramento South Regional Office Representatives, Licensing Program Manager (LPM) Stephen Richardson on behalf of Regional Manager (RM) Stephenie Doub , LPM Czarrina Camilon-Lee, Licensing Program Analyst (LPA) Christina Valerio, and facility representative Administrator Molini Mataele LPM Czarrina Camilon-Lee, LPA Christina Valerio, and LPM Stephen Richardson went over and read the Stipulation and Waiver; Order, in it's entirety, to all persons present. Topics discussed during the meeting: Findings Revocation - Stayed with Probation Exclusion - Stayed with Probation Future Application for a License, Registration, Certification, or Approval Tolling of Probationary Period Completion of Probation Violation of Stipulation Term Department's Authority Monitoring Fee Waiver of Hearing Rights Waiver of Appeal/Modification Rights Continues on LIC 809 - C... ... Continued from LIC 809 Topics Discussed During the Meeting: Waiver of Claims Public Period Signatures Counterparts Effective Date: (February 5, 2025 - February 5, 2027) No Oral Modification The Licensees/Respondents/Representatives stated they would abide by the following: Abide by the contents/terms of the Stipulation (submit all documents timely) Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly 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 Post the Stipulation in a conspicuous place at the facility for the duration of the probationary period Maintain an accurate, complete, and current client roster which must be made available to the Department upon review 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. Administrator Molini stated she will submit the following updated documents by COB 02/19/25 LIC 9020 Register of Facility Clients/ Resident LIC 500 Personnel Roster LIC 308 Designation of Responsibility CCL will do the following: Increased monitoring by CCL Staff Technical Support Program (TSP) was offered to Administrator Molini Mataele. Administrator agreed to participate. The Sacramento South Regional Office (RO) will be referring the facility to TSP. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email. Administrator to sign hard copy and send back to LPA Valerio by COB 02/19/2025.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Case Management - Other

On 10/3/24 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould and Licensing Program Manager (LPM) Liza King conducted an unannounced case management inspection to ensure the replacement of resident who was moved next door to an unlicensed facility. LPA and LPM met with licensee and discussed to reasoning behind licensees decision to move resident next door and the explained the departments purpose of our inspection today. Licensee was informed resident must be readmitted to the facility and must remain at the facility until they or their authorize representatives decide to exit the facility or the facility has proved a 30 day notice due to capacity limitations. The department has also informed the licensee, as the resident is currently identified as non-ambulatory, they must notify the fire department once returned to the facility and issue a 30 day notice to the resident and their authorized representative by 10/4/24 and provide a copy to the department. Technical assistance was provided to seek guidance from fire department on changing capacity if facility wishes to pursue a change in capacity and non-ambulatory capacity. Exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Kesha Lewis and Charlie Yang arrived at the facility unannounced for the purpose of a health and safety check following an unlicensed complaint at the licensees home that is next door to the facility. LPA explained purpose of visit to the to staff. Based on observations, and interview the licensee moved a resident from the licensed facility to their personal home. Based on observations LPA Lewis and Yang saw two beds in the facility that had full bed rails. The licensee has two residents that have hospital beds with full bed rails and are not on hospice. The licensee was interviewed and stated that the residents were not on hospice but that some times there feet would fall off the side so sometimes they would out just the top rail up and sometimes they put the whole rail up. Per California Code of Regulations, Title 22 deficiencies were observed and are being cited during today's case management inspection. An exit interview was conducted and a copy of this report and appeal rights was given.the state’s words, verbatim · CDSS document, Oct 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Oct 3, 2024

87405 Administrator - Qualifications and Duties. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not meet as evidenced by: Based on observations, and interview the licensee moved a resident from the licensed facility to their personal home. therefore they not comply with the section cited above. The licensee did not ensure thay complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Administrator agrees to take training including but not limited to the following: Title 22 regulations, care and supervision and duties and responsibilities. Training topics and dates shall be submitted by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(5)(a)(b) · Plan of correction due date: Oct 3, 2024

87608 Postural Supports(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A)A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. Based on observations, and interview the licensee has 2 resident have hospital beds that have full bed rails and are not on hospice. This posed a immidate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee agrees to remove fails for the beds of both residents and send proof to LPA Lewis by POC date.

Allegation investigated: Facility accepted resident without authorization Staff did not provide resident's records to their responsible party as necessary Wrongful Eviction

On 9/24/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to complete and delivery findings for a complaint investigation with the allegations above. LPA met with Licensee Molini Mataele and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Regarding the allegation, “Facility accepted resident without authorization” LPA obtained the following information through interviews. It was learned that the facility admitted resident #1 (R1) without R1’s Power of Attorney (POA) consent and agreement. R1 was admitted on 6/1/2024. It wasn’t until 7/2/2024 that R1’s responsible party was contacted to do admission paperwork. Regarding the allegation, “Staff did not provide resident’s records to their responsible party as necessary” LPA obtained the following information through interviews. It was learned that the facility did not provide R1’s responsible party with proper admission agreement upon admitting R1. Facility also did not provide proof of current liability insurance to R1’s responsible party as requested. Continued on 9099-C Substantiated Regarding the allegation, “Wrongful eviction” LPA obtained the following information through interviews. It was learned that the facility drops off R1 at the hospital due to nonpayment. The facility did not provide R1 and R1’s responsible party with a 30-day eviction notice as required by Title 22 Regulations. As a result of the investigation, LPA finds the allegations above to be SUBSTANTIATED- A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 27-AS-20240715120959

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(b) · Plan of correction due date: Oct 8, 2024

87457(b) Pre-admission Appraisal - No person shall be admitted without his/her consent and agreement, or that of his/her responsible person, if any. This requirement is not met as evidenced by: Based on records review and interviews, the licensee admitted R1 without R1’s responsible party consent and agreement which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee shall review and send a statement of understanding of this regulation to CCL by the close of POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Oct 8, 2024

87507(c) Admission Agreements. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not provide the resident’s representative the admission agreement following admission which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee shall review and send a statement of understanding of this regulation to CCL by the close of POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Oct 8, 2024

87224(a) Eviction Procedures: the licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... This requirement is not met as evidenced by: Based on file review and interviews, the Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Licensee shall review and send a statement of understanding of this regulation to CCL by the close of POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit on 9/24/24. LPA met with Licensee Molini Mataele and explained the purpose of today’s visit. The purpose of the visit is to follow up on deficiencies learned during complaint investigation, COMPLAINT CONTROL NUMBER: 27-AS-20240715120959. Through the complaint investigation, it was learned that the licensee admitted resident (R1) without R1’s responsible party consent and agreement. It was also learned that the licensee did not provide the resident’s representative the admission agreement within 7 days following admission. In addition, it was learned that the licensee did not follow eviction procedures outlined in Title 22 Regulations. The Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice. As a result, the following deficiency was cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency can be found on the 809-D page. Exit interview was conducted, and a copy of this report, 809-D, and appeal rights given to the facility.the state’s words, verbatim · CDSS document, Sep 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Oct 8, 2024

87405 Administrator - Qualifications and Duties. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: Administrator agrees to take in-service training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC due date.

Type of visit: Post Licensing

On 7/23/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a post-licensing inspection. LPA met with Licensee Molini Mataele and explained the purpose of the visit. Administrator’s certificate is current and will expire on 9/15/25. The facility is licensed for six (6) ambulatory, of which two (2) may be non-ambulatory in room 1#. Current census is 1. LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature was measured at 110.3*F which was within the required range of 105-120*F. The temperature inside the facility was observed to be at 70*F which was within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the clients at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA reviewed (1) client files and (2) staff files, including criminal record clearances. LPA confirmed all residents’ files have required records. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. Per California Code of Regulations, Title 22, there were no deficiencies cited during today's inspection. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Prelicensing

On 11/9/23, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Truong met with Applicant Molini Mataele, who assisted LPA Truong in today’s inspection. LPA Truong toured the facility with Applicant Molini Mataele. There was 1 resident in care currently. LPA reviewed resident's file. During today's visit, all corrections were completed, and the applicant has passed the pre-licensing visit. - Garage door was unable to close and need to be repaired or replaced. Completed. - Air vent in bathroom #1 is not working and need to be repaired or replaced. Completed. - Each resident rooms need to be well furnished and in good repair. Completed. - Backyard shall be kept free of debris and obstruction of potential hazard. Completed. - Windows, doors, and baseboards were not clean. Completed. - Cleaning supplies need to be kept lock and away from the kitchen. Completed. - Faucet in bathroom #1 is not in good repair and need to be repaired or replaced. Completed. Pre-Licensing is complete, and this facility has no deficiencies. A Component III was completed at this time with the applicant. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report was given to the applicant.the state’s words, verbatim · CDSS document, Nov 9, 2023

Type of visit: Prelicensing

On 10/6/2023 at 2:00 PM, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA met with Applicant, Molini Mataele who assisted LPA in today’s inspection. It was learned that this facility will be licensed to serve up to 6 ambulatory residents of which 2 may be non-ambulatory in bedroom #1 only. There was 1 resident in care during today's pre-licensing visit. LPA toured the facility with Applicant Molini Mataele. Dining area, living area, and all other areas intended for client use were toured and observed to be furnished and maintained in compliance at this time. LPA observed no obstruction of emergency exits. Fire extinguisher was observed and is up to date. Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Medication cabinet was observed. First aid kit was observed to be present and contained all required components at this time. A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the residents were observed to be insufficient to meet the needs of the residents at this time. A tour of the client bathrooms was conducted. Hot water temperatures were taken and measured at 108.0 degrees Fahrenheit. Continued on 809-C A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed. A tour of the laundry room and garage was conducted. During today's visit, LPA observed the facility was overall in good repair. There were a few items that need corrected. The following items that need to be corrected were as follows: - Garage door was unable to close and need to be repaired or replaced. - Air vent in bathroom #1 is not working and need to be repaired or replaced. - Each resident rooms need to be well furnished and in good repair. - Backyard shall be kept free of debris and obstruction of potential hazard. - Windows, doors, and baseboards were not clean. - Cleaning supplies need to be kept lock and away from the kitchen. - Faucet in bathroom #1 is not in good repair and need to be repaired or replaced. As a result, the facility has not passed today's pre-licensing inspection. LPA Truong will return to the facility when the corrections have been made. Applicant was informed to call LPA Truong when the correction has been completed. An exit interview was conducted, and a copy of this report was given to the applicant.the state’s words, verbatim · CDSS document, Oct 6, 2023