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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700440
Report Date: 08/06/2021
Date Signed: 08/10/2021 04:02:15 PM



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
04/01/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210401085035
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:
08/06/2021
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Mike HerTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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9
-Resident was physically assaulted while in care.
-Staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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13
This LIC9099 report and LIC9099-D is being Amended to reflect the proper Title 22 Regulation being cited. The proper Regulation should read 87468.1(a)(14).

On 8/6/2021, Licensing Program Analyst (LPA) Chris Hopkins, conducted an unannounced visit to this facility to deliver the investigation findings. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with assistant administrator Mike Her.

The investigation was conducted by the Department which consisted of reviews of records and interviews with facility management and staff. The complaint alleges that facility staff failed to seek timely medical attention for resident.

Throughout the course of the investigation, the Department conducted interviews and reviewed records. The investigation revealed that on 3-29-2021, R1 was involved in an altercation with another resident, R2. After the incident, R1 had complained of pain for several days but was not given medical treatment. Per facility policy, if a client has complaints of pain after a fall or incident, the client is to be sent to the hospital. The facility failed to follow their own policy which resulted in R1 was not accorded timely medical attention.

Report Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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 6
Control Number 27-AS-20210401085035
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: 08/06/2021
NARRATIVE
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The complaint also alleges that staff did not follow reporting requirements.

Based on interviews conducted and reviewed of records, On 3-28-21, R1 fell in the facility and hurt her head. On 3-29-21, R1 was assaulted by another resident, R2, that resulted in multiple bruises while at the facility. Staff did not allow R1 to call local enforcement to file the report when R1 asked to call. Additionally, Community Care Licensing does not have copies of the incident report regarding the above incidents.

This Department has investigated the allegations noted above and have found that the complaint was SUBSTANTIATED, A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per Title 22 Regulations, Division 6 and/or Health and Safety Code, deficiencies were cited on 9099-D.

Exit interview was conducted with Assistant Administrator Mike Her, a copy of the report, LIC 9099-D and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20210401085035
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: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2021
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care Services: 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including a apparent life-threatening medical crisis.
This requirement is not met as evidence by:
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Licensee/Administrator shall submit a written plan on how the facility staff will ensure that residents are provided timely medical care moving forward. The licensee, administrator and all staff shall attend training from a vendor approved by CCL on resident rights. Provide proof of training certificate to all staff who attended.

POC plan to be submitted to CCL no later than POC due date 8/9/21.
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14
Based on interview and records review the Licensee did not seek timely medical attention for R1. R1 on 3/29/21 was involved in an altercation with another resident. R1 complained to licensee of having pain for several days but licensee did not contact 911 to have R1 sent out for further assessment. This poses an immediate health and safety risk to residents in care.
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Type B
08/09/2021
Section Cited
CCR
87468.1(a)(14)
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87468.1(a)(14) Personal Rights: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.

This requirement is not met as evidenced by:
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Administrator has agreed to give residents reasonable access to make confidential phone calls. The licensee, administrator and all staff shall attend training from a vendor approved by CCL on resident rights. Provide proof of training certificate to all staff who attended.
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The facility did not allow R1 to call law enforcement when R1 requested after an altercation with another a R2, which poses a potential risk to the health and safety risk to 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20210401085035
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: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2021
Section Cited
CCR
87211(a)(1)(D)
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87211. Reporting Requirements. Each licensee shall furnish to the licensing agency such reports...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidence by:
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Administrator shall review reporting requirements under section cited and provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations regarding reporting requirements and agrees to report as required in the future.
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Based on interview and records review the Licensee did not submit an Unusual Incident Report to CCL regarding R1 requiring 911 on 03/29/21, which poses an immediate health and safety risk to 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
04/01/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210401085035

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:
08/06/2021
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Mike HerTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Lack of Supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
10
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12
13
On 8/6/2021, Licensing Program Analyst (LPA) Christopher Hopkins conducted an unannounced visit to this facility to deliver the investigation findings. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with assistant administrator Mike Her.

The investigation was conducted by the Department which consisted of reviews of records and interviews with facility management and staff. The complaint alleges that resident (R1) has sustained egregious injuries as a result of lack of supervision from the staff.

Throughout the course of the investigation, the Department conducted interviews and reviewed records. The investigation revealed that on 3-29-2021, R1 was involved in an altercation with another resident (R2). Staff (S1) witnessed the altercation from the kitchen window, which has a clear view of the backyard. S1 immediately stopped the altercation and separated R1 and R2. The supervision provided by S1 was appropriate based on residents’ needs.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20210401085035
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: 08/06/2021
NARRATIVE
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3
4
5
6
7
8
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12
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This Department has investigated the allegation noted above and have found that the complaint was UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview was conducted with Assistant Administrator Mike Her and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6