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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700440
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:09:16 PM


Document Has Been Signed on 04/14/2022 04:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
342700440
ADMINISTRATOR:NONU, JULIE ADRIANNAFACILITY TYPE:
740
ADDRESS:27 TRISTAN CIRTELEPHONE:
(916) 619-8590
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Julie NonuTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA)s Jamie Ivey Canady and Christina Valerio arrived unannounced at the facility to conduct a case management visit due to a stipulation order in place for Abounding Love Home Care.
LPAs toured the facility. LPAs observed the stipulation order was posted on a wall in a conspicuous place in the facility. According to the stipulation order, Mike Her, Deborah Saunikalau, and Anthony Camacho are excluded and shall not be on the premises. LPAs did not observe those individuals during the visit. LPAs observed two facility staff, Staff 1 and Staff 2, which both staff are fingerprinted, cleared and associated with the facility. LPA observed auditory devices on exit doors were working throughout the facility. LPA observed all medications to be locked and properly stored and kept in a safe and locked place that is not accessible to persons other than employees. The facility is clean safe and sanitary. The dining table was observed to be unbalanced and in poor condition. The couch in the common area is ripped and torn on the arm and seating of the couch. LPA observed there to be no safety hazards on the flooring in the facility. Administrator Julie stated there are new couches and tables located in an a storage area that is accessible for the facility and all furniture items will be replaced within 24 hours.








Per California Code of Regulations Title 22, Division 6 Chapter 8, deficiencies were observed and cited on LIC 809-D. Failure to correct deficiencies may result in civil penalties. Exit interview held and a copy of the report was given to Administrator Julie.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 04:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited

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87307 Personal Accomadations and Services (d). The following space and safety provisions shall apply to all facilities: (2)The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure the furniture in the common areas were maintained in good condition. Furniture was observed to be in worn condition and need of replacement. This poses a potential health and safety risk to persons 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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