Friends House

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management for change in fire clearance and was greeted by Administrator, Robert Rubio. On 11/6/25 Santa Rosa Fire Department (SRFD) conducted a fire inspection and fire clearance was granted for a single family dwelling unit (SFD) at 645 Bambi Lane, Santa Rosa, CA 95409. SFD has a capacity of two (2). Facility already has three (3) other SFD units with fire clearance granted at: 637 Bambi Lane with a capacity of two (2), 641 Bambi Lane with a capacity of two (2), and 649 Bambi Lane with a capacity of two (2). All SFD units are part of the Independent Living (IL) portion of the facility. Although the licensee has added the SFD unit, an increase in capacity is not being requested at this time. At approximately 3:00pm LPA and Admin toured 645 Bambi Lane. All exits were free from obstruction. LPA did not observe any tripping hazards present. LPA and Admin toured residence. SFD is a one story three (3) bedroom two (2) bath with a large outdoor deck. Smoke alarms and carbon monoxide detectors are present and operational. As of today 11/13/25, LPA advised Admin that IL residents can now occupy the SFD at 645 Bambi Lane. In addition to today's fire clearance inspection visit, LPA discussed with Admin a recent incident report (IR) received on 11/10/25. IR submitted for R1 indicating they had eloped from the facility on 11/2/25. Previously, R1 had eloped on 10/10/25 and LPA cited the facility for the elopement on 10/31/25. At approximately 9:45pm on 11/2/25, facility was notified by EMTs that they had R1 and were transporting them to the hospital. Facility was informed that R1 would not be returning to the facility as they were admitted to skilled nursing. Subsequently, facility had meeting with R1's responsible party. Responsible party advised Admin that R1 now requires a higher level of care than Friend's House can provide and so R1 will not be returning. Continued on 809C... Continued from 809... Facility conducted staff training on elopement prevention and resident redirection. Additionally, facility put in place Wanderguard, a wander management system. R1 was participating in Wanderguard by wearing a bracelet, but on the day of the incident, the bracelet was found to be removed from R1's person. Admin advised LPA that facility does not view the implementation of Wanderguard as a total means of protection against elopement. So, facility has also implemented a one hour check policy for all those residents identified as an elopement risk. LPA discussed with Admin the importance of staff awareness regarding elopement, wandering, and sundowning behavior. Admin advised LPA that they are selective in screening potential residents and acknowledge and value the need to appropriate supervision. LPA and Admin discussed personal rights regulation 87468.2(a)(4), that all residents must receive care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. No citations issued at this visit. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Coppo conducted an unannounced annual inspection and met with Administrator Robert Rubio. Robert Rubio Administrator Certificate 7021430740 expires 1/21/26. There are currently 14 residents living in the Assisted Living (AL) portion of the facility and 67 residents living in the Independent Living (IL) portion of the community. Five (5) residents were receiving hospice care at the time of the visit. Required postings were observed. At approximately 10:30am LPA toured assisted living portion of the community including the resident rooms/apartments, activity rooms, grounds and kitchen (located in the assisted living). All interior parts of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured 118.7 degrees F which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Bathrooms contained necessary grab bars and non-skid strips. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. Fire extinguishers were current and charged as of 4/10/25. Fire alarm system was tested and inspected by vendor August of 2025. Latest disaster drill was conducted on 9/23/25. At approximately 12:00pm LPA conducted a review of seven (7) resident records. Files complete. Continued on 809C... Continued from 809... At approximately 1:30pm LPA conducted review of seven (7) staff records. Files complete. At approximately 2:30pm LPA conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. R2 had a bubble pack of Quetiapine FUM 50mg not listed on Centrally Stored Medication Log (CSML) (deficiency cited, see 809D). LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. In addition to Annual inspection, LPA discussed with Admin Incident Report received on 10/15/25 indicating resident (R1) had eloped from the facility. Incident report indicated that on 10/10/25 resident (R1) eloped from the facility. R1’s physician report indicates that they are not allowed to leave the facility unassisted. Facility notified R1’s family. R1 had location device on their person as placed by their family. R1 was found at the adjacent local grocery store shopping for food. R1 was safely escorted back to the facility by staff. Facility held a care conference with R1’s family and facility staff. The local ombudsman was also notified and held a meeting with R1’s family. Facility has put Wanderguard in place to help address elopement and R1 has received their Wanderguard bracelet as of today. A follow-up care conference was held with R1’s family the week of 10/20/25 (deficiency cited, see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was giventhe state’s words, verbatim · CDSS document, Oct 31, 2025

Allegation investigated: Facility is not ensuring resident’s incontinence needs are me

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility deliver complaint findings on the above allegations. LPA met with Administrator Robert Rubio. Complaint alleges facility is not ensuring resident’s incontinence needs are met. During investigation, LPA conducted interviews with staff and asked if facility has a written incontinence procedure. Facility unable to provide LPA with their written incontinence care protocols. Five [5] out of five [5] staff interviewed indicated that there is nothing in writing but that they get trained to check every 2 hours, by asking the residents verbally if they need to be changed. If a resident refuses, then they keep on asking, sometimes switching up the specific staff that asks, until the resident agrees. One staff indicated facility wants the residents to use their pendant to request incontinent care. Five [5] out of five [5] indicated they do get training from Relias but not specifically on incontinence care. All staff indicated they do get training on grooming and behaviors, some of Continued on 9099C... Substantiated Continued from 9099... which include incontinence care, but nothing just on incontinence care alone. During investigation, LPA interviewed residents. One [1] resident available for interview did not require incontinence care and one [1] resident available for interview did not have continuity of cognitive function or capacity to answer LPA’s questions. Three [3] out of five [5] residents indicated they use their pendants to alert staff as to when they need incontinence care. Residents indicate that the only time staff show up outside of them pressing their pendant is when they are giving them their medications. Three [3] out of five [5] residents indicated they typically have to wait between 5-15 minutes after pressing their pendant to get incontinence care, with one reporting that the longest they waited was about 30 minutes. Facility has current residents that have declining cognitive functioning such that they cannot properly communicate their needs or have ability to remember to press their pendant should they have a care need. The pendant response wait time paired with the facility’s lack of written procedure for incontinent care meets the preponderance of evidence. Therefore, based on LPA’s interviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 21-AS-20250428125354

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87611(e) · Plan of correction due date: Jul 8, 2025

87611 General Requirements for Allowable Health Conditions (e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met. This requirement not met by licensee as evidenced by: Based on LPA interview and record review, the licensee did not comply with the section cited above in that facility does not have an incontinence care program/procedure that addresses and/or ensures that the facility meets the needs of those residents that lack the cognitive capacity to communicate their incontinence needs, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Facility to formulate and implement an incontinence protocol procedure and add it to facility's plan of operation. Facility to then conduct in-service training on newly established incontinence care protocols with direct care staff. In-service training to be conducted no later than 7/22/25 and submit to CCL training sign-in sheet

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Coppo conducted an unannounced annual inspection and met with Administrator Robert Rubio. There are currently 10 residents living in the Assisted Living (AL) portion of the facility and 69 residents living in the Independent Living (IL) portion of the community. Two [2] residents were receiving hospice care at the time of the visit. Required postings were observed. At approximately 1:30pm LPA and Admin toured assisted living portion of the community including the resident rooms/apartments, activity rooms, grounds and kitchen (located in the assisted living). All interior parts of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured between 119.7 and 109.5 degrees F which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Bathrooms contained necessary grab bars and non-skid strips. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. Fire extinguishers were current and charged as of 4/4/2024. Fire alarm system was tested and inspected by Santa Rosa Fire Equipment Inc on 4/22/24. Latest disaster drill was conducted on 9/3/24. At approximately 2:00pm LPA conducted a review of 10 resident records. Residents R1 and R2 did not have a TB clearance on file (deficiency, cited, see 809D) Continued on 809C... Continued from 809... At approximately 3:30pm LPA conducted review of 5 staff records. Staff members S1 and S2 did not have 20 hours of annual training completed. S1 had 7 hours and S2 had 10.5 hours (deficiency cited, see 809D) At approximately 4:15pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies Robert Rubio Administrator Certificate 7021430740 expires 1/21/26. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Staff are not preventing resident from smoking in the facility Staff are not providing a comfortable environment for resident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced at the facility and met with Korina Weatherson, Sales Manager to deliver findings regarding the complaint allegation above. Administrator Robert Rubio was not able to come to the facility, but was present via telephone and gave authorization for Korina Weatherson, Sales Manager to sign the report. Staff are not preventing resident from smoking in the facility--It is alleged by Reporting Party that staff are not preventing resident from smoking in the facility. Reporting party reported knowledge of a resident smoking in unauthorized areas adding that the facility is a non-smoking facility. Per LPA conversation with Administrator, they have done the following to address smoking at the facility: • Conduct Care conference with resident and spouse to address allegations of smoking • Provided an alternative location away from residences for resident to smoke that is more than 25 feet away from any residence, as required by the County of Sonoma ordinance (chapter 32) Continued on 9099C... Unsubstantiated Continued from 9099... A finding that the complaint allegation that staff are not preventing resident from smoking in the facility is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Staff are not providing a comfortable environment for resident---It is alleged by Reporting Party that staff are not providing a comfortable environment for resident as evidenced by resident smoking in unauthorized areas, which results in other resident(s) being affected by the smoke. Per LPA interviews with potentially affected residents, they acknowledge that a neighbor is smoking but are not bothered by it. Other residents report never smelling smoke or observing residents smoking. LPA was unable to obtain any information to support that staff are not providing a comfortable environment for residents. A finding that the complaint allegation that that staff are not providing a comfortable environment for resident is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 6, 2024 · control 21-AS-20231215094751

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Required - 1 Year annual inspection and met with Executive Director, Robert Rubio. There are currently 9 residents living in the Assisted Living (AL) portion of the facility and 83 residents living in the Independent Living (IL) portion of the community. There are residents with a diagnosis of dementia and no residents were receiving hospice care at the time of the visit. Required postings were observed. Facility contact information was reviewed. Fees are current at the time of visit. Beginning at 9:00 AM, LPA/Administrator toured assisted living portion of the community including the resident rooms/apartments, activity rooms, grounds and kitchen (located in the assisted living). All interior parts of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured between 112.8 and 113.4 F in faucets used by residents which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Bathrooms contained necessary grab bars and non-slip floor/mats. Toxins were observed to be inaccessible in the Assisted Living portion of the community. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. Medications are centrally stored in a locked office in the assisted living building. Fire extinguishers were current and charged as of October 2023. Fire alarm system was tested and inspected and documentation of last semi-annual inspection conducted on 11/29/2023 was provided during the visit. A disaster drill was conducted on September 2023. Carbon monoxide detectors were observed to be present and in working order. Continued on LIC809C... Continues from LIC809... LPA initiated file review at 10:00am nine resident and five staff records. Six out of nine residents (R1, R2, R3, R4, R5 & R6) care plans has not been updated within the last 12 months. One out of nine residents (R3) has not been updated within the last 12 months. Five staff records were reviewed. Staff have CPR/1st aid certificate. Two out of five staff (S1 & S2) does not have 20 hours of required annual training on file. A spot check of Medication and medication records was also conducted. Administrator Robert Rubio's Certificate 6054931740 expires 1/21/2024. Administrator agrees to submit the following documents updates to CCL by 12/22/2023: -LIC308 - Designation of Administrator Responsibility -LIC500 - Personnel Report -Updated Liability Insurance Certificate. -Control of property. -LIC610E - Emergency Disaster Plan & Updated Evacuation Plan Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrator and a copy of the report was given.the state’s words, verbatim · CDSS document, Dec 15, 2023