342700440-8-29-2024-27-AS-PLEE-D8LUDY-20240829153018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700440
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:30:29 PM

Document Has Been Signed on 08/29/2024 03:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ABOUNDING LOVE HOME CARE		FACILITY NUMBER:	342700440
ADMINISTRATOR:	NONU, JULIE ADRIANNA		FACILITY TYPE:	740
ADDRESS:	27 TRISTAN CIR		TELEPHONE:	(916) 619-8590
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Qalo Saurara and Akuila Saukuru		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/29/2024 at 12:21 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with direct care staff Qalo Saurara and Akuila Saukuru. LPA Lee explained the purpose of today’s visit. A brief telephone call was made to administrator Julie Nonu. Care staff Qalo assisted with today’s inspection. Administrator Certificate # 6038867740 expires on 03/03/2024. Administrator renewed her administrator certificate, and it was learned that the Administrator Certification Bureau (ACB) has received the renewal on 02/27/2024. The current census is 5 with 2 facility staff. This facility is a single story building licensed to served 6 non-ambulatory residents which 1 may be bedridden. The facility is also approved for 2 hospice waivers. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedroom, resident bathrooms, laundry rooms, staff room and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed resident bathroom #1 had a urine odor. During today’s visit, administrator disinfected and cleaned resident bathroom #1. Administrator stated that the non-skid mat probably needed to be cleaned and that it was probably holding urine which may has caused the urine odor. The facility was observed to be clean and in good repair. LPA observed resident bedrooms to be properly furnished with appropriate bedding and lighting. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 106.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguishers are located in the common area and were last serviced on 11/06/2023. LPA observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 74 degrees Fahrenheit. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING LOVE HOME CARE	FACILITY NUMBER: 342700440
	VISIT DATE: 08/29/2024

NARRATIVE

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LPA observed toxins located in the laundry cabinet kept locked and inaccessible to residents. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 5 medication administration record (MAR) along with residents’ medications and it was complete. LPA asked to inspect the facility’s first aid kit and it was complete. LPA requested residents and staff files for review. LPA reviewed 5 out of 5 resident files and they were complete. LPA reviewed 3 out of 3 staff files and they were complete.. LPA Lee reviewed staff criminal record clearances and 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.

The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by 09/06/2024 end of day 5:00 PM.

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) LIC 610 Emergency Disaster Plan
(4) Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency 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.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2024 03:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING LOVE HOME CARE	FACILITY NUMBER: 342700440
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA Lee observed resident bathroom #1 had a urine odor which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	During today’s visit, administrator disinfected and cleaned resident bathroom #1. Administrator will conduct a cleaning schedule for the resident bathroom and provided LPA Lee the cleaning schedule. Administrator will also read the regulation being cited and write a statement of acknowledgement of understanding of the regulation. POC will be emailed to LPA Lee by POC date 09/06/2025 by 5:00 PM by end of day.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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