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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700440
Report Date: 10/22/2020
Date Signed: 10/22/2020 10:31:45 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2020 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200416163625
FACILITY NAME:ABOUNDING LOVE HOME CAREFACILITY NUMBER:
342700440
ADMINISTRATOR:NONU, JULIE ADRIANNAFACILITY TYPE:
740
ADDRESS:27 TRISTAN CIRTELEPHONE:
(916) 547-0206
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
10/22/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Julie NonuTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility failed to follow client reassessment due to AWOL behavior.
Facility failed to report client AWOL in March 2020.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Suong Teh contacted the facility via telephone to commence a complaint investigation via telephone on 10/22/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation(s) with the facility administrator Julie Nonu.

On 04/17/2020 the Department conducted an initial 10 days complaint investigation.
On 04/16/2020 the Department received a call from the Reporting Party (RP)to report client 1 (C1) AWOL from Abounding Love Home Care on 04/14/2020. RP stated that this was C1 third AWOL since he was admitted in November 2019. The RP stated that the first AWOL occurred on 02/10/2020; The second AWOL occurred on 03/31/2020, and the current AWOL occurred on 04/14/2020. RP stated that the facility administrator reported that C1 is able to turn the door exit alarm off. On 04/17/2020, the Department interviewed staff 1 (S1). S1 stated that C1 had AWOL from the facility about three times. S1 could not remember the date when C1 first AWOL. However, S1 stated that C1 second AWOL was on 03/31/2020 and the third AWOL occurred on 04/14/2020. S1 reported to observe C1 slept on the living room couch early morning on 04/14/2020. S1 stated that she checked on C1 at~0700 – 0730 hours and discovered that C1 was missing.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20200416163625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ABOUNDING LOVE HOME CARE
FACILITY NUMBER: 342700440
VISIT DATE: 10/22/2020
NARRATIVE
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. S1 reported to be the only live-in care giver. S1 confirmed that the facility currently has four (4) clients and out 4 clients, 3 clients are on AWOL checklist. S1 stated that on 04/14/2020 morning, S1 did not hear the door alarms activated. S1 confirmed that all exit door alarms were operable. On 04/21/2020 the Department interviewed the facility administrator Julie Nonu. Julie stated that this was C1 second AWOL since he moved to Abounding Love Home Care. Julie stated that C1 first AWOL was on 04/07/2020 about a week after the second AWOL 4/14/2020. Julie was not able provide to licensing evidence of an AWOL report which she stated that the AWOL occurred on 04/07/2020. NOTE: The Department learned that there was no AWOL incident report submitted to licensing in 02/10/2020, 03/31/2020 and 04/07/2020. C1’s appraisal/needs and services plan stated an updated care plan was addressed about the wandering/AWOL dated 03/01/2020. The facility objective/plan stated the supervision by installing new door alarms; 15 minutes checks and up activities.

Based on LPA interviews were conducted, and resident records were reviewed, the licensee did not follow C1’s appraisal/needs and services plan. Licensee did not report C1 first and second AWOLs to licensing. Due to the preponderance of evidence standards has been met, therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200416163625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ABOUNDING LOVE HOME CARE
FACILITY NUMBER: 342700440
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2020
Section Cited
CCR
87465(a)
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87465(a) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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Licensee agrees to submit a written plan of correction to LPA by 10/23/2020 on how the licensee will be in compliance with regulation 87465(a) at all times.
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This requirement is not met as evidenced by: Based on LPA interviews were conducted, and resident records were reviewed, the licensee did not follow C1’s appraisal/needs and services plan. This poses a potential health risk to the residents in care.
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Type A
06/23/2020
Section Cited
CCR
87211(a)(1)(a)
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87211(a)(1) (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 of any of the events specified in (A) through (D) below.
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The administrator agrees to conduct a reporting training by POC date 10/23/20. Administrator will email LPA training materials and sign in sheet.
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This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on LPA interviews were conducted, and resident records were reviewed, the licensee did not report to licensing regarding C1 first AWOL occurred in January 2020 and second AWOL occurred in March 2020. This poses a potential health risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3