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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700440
Report Date: 09/15/2021
Date Signed: 09/15/2021 10:36:06 AM

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:
09/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Julie NonuTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 9/15/21 at 9:45AM. LPA met with Julie Nonu and stated the purpose of today’s visit. Community Care Licensing received an incident report indicating that resident #1 (R1) left the facility on 9/6/21.

On 9/13/21, LPA interviewed the Administrator and the Caregiver regarding the absence of R1.
The staff on duty had no knowledge of the Absence without Leave (AWOL) until police contacted the Administrator. Upon a review of the most recent Physician Report (LIC602) dated 2/16/21, it indicates that R1 is not able to leave the facility unassisted.

Upon arrival LPA observed staffing walking with R1. R1 stated they were looking for a car but they went the wrong way. Administrator has made an appointment for R1 to be seen by physician on 9/17/21 to re-assess the residents medications.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

The regulation for Care of Persons with Dementia was previously cited on 4/2/21. Therefore, a civil penalty shall be assessed for a repeat violation within a 12-month period during this visit. You are hereby assessed an immediate civil penalty in the amount of $250.00.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held with Administrator. A copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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
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: 09/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2021
Section Cited

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Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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This requirement is not met as evidenced by: CCL received an incident report from facility stating that R1 Awol’d from the facility.
Based on confirmation of the Administrator the staff did not hear the alarm on the door while R1 Awol’d from the facility.
This 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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