Friends House, a licensed assisted‑living facility in Santa Rosa, has undergone a series of unannounced inspections from 2021 through 2023. Over the past three years the facility has consistently met the Department of Social Services’ requirements for infection control, fire safety, and basic environmental standards. Each annual inspection in 2021 and 2022 confirmed that temperature logs, hand‑sanitizer stations, personal protective equipment supplies, and medication and toxin storage were adequate and that residents were able to isolate when needed. The LPA observed a clean, well‑maintained building with clear pathways, functional fire extinguishers, and current emergency systems, and no deficiencies were cited.

Despite the strong compliance with infection‑control protocols, the June 2023 case‑management visit highlighted a significant resident safety issue. A resident fell in February, declined medical treatment, and was later found to have a mild fracture. The review emphasized the need for timely incident reporting and reinforced the regulatory requirement for accurate, current incident documentation. The facility’s staff had not submitted the February incident report in a timely manner, raising concerns about documentation practices.

The most substantial concerns emerged during the December 2023 required annual inspection. While the facility maintained physical safety and environmental standards, the evaluation uncovered several administrative deficiencies: six of nine resident care plans had not been updated in over a year, two of five staff members lacked the mandated 20 hours of annual training, and essential licensing documents—such as the updated emergency disaster plan and liability insurance—were incomplete. These lapses were cited under California Code of Regulations Title 22 and could result in civil penalties if not corrected. The administrator was directed to submit updated care plans, staff training records, and required licensing documentation by early January 2024.

Overall, Friends House demonstrates strong adherence to infection‑control and environmental safety standards, but must address gaps in administrative documentation, resident care‑plan updates, and staff training to fully meet regulatory expectations and safeguard resident well‑being.