342700440-10-11-2021-27-AS-RWAE-C7PQ3D-20211011114833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700440
Report Date: 10/11/2021
Date Signed: 10/11/2021 02:00:04 PM

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 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: 6	DATE:	10/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	JULIE NONU - ADMINISTRATOR		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Ruth Wallace arrived to the facility approximately 9:15 am to conduct an unannounced Annual Inspection visit to the facility on today's date of 10/11/21. LPA was greeted by Administrator Julie Nonu and staff Atelaite Peti. LPA explained that the purpose of the visit was to conduct an required annual inspection. Currently, there are 6 residents that live in the home. Julie Nonu Administrator Certificate #6038867740 expires 03/03/2022. LPA evaluated the physical plant to ensure the health and safety of the residents in care. LPA inspected the facility with Administrator including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room, and backyard. Next to Bathroom behind kitchen area window screen needs to be replaced. Bathroom behind kitchen needs grout replace and mold repaired in shower area. The facility had the required carbon monoxide detectors and fire extinguishers expire 6/4/2022 LPA observed the facility to be free of odor, clean and in good repair. There are no bodies of water present in the facility at this time. LPA observed sufficient seven day non-perishable and insufficient two day perishable food supplies. All 6 resident room smoke detectors were tested and all were operable. Hot water registered at 115.9 F. LPA reviewed 6 resident and 3 staff files, and criminal record clearances. No residents on hospice at this time. 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. Continued on 809-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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
	VISIT DATE: 10/11/2021

NARRATIVE

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Continued from 809 - Page 2

The following documents needed to be submitted to licensing by November 15, 2021:
Admissions Policies and Procedures, Plan of Operation, Administrator Certificate, and Transportation Policies, and a copy of Liability Insurance
LIC 308 Designation of Administrative Responsibility, LIC 309 Administration Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited today. Failure to correct cited deficiencies by the noted due date; civil penalties may be assessed.

Exit interview conducted. A copy of this report was left with Administrator.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above. The bathroom behind kitchen had mold above shower tile area and grout needs to be replaced in shower which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2021
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above. Window screen in window behind kitchen area had large rip in screen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	LPA observed window screen being replaced while at facility. POC cleared on 10/11/21.

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 Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above. The facility did not have a two day supply of perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	LIcensee purchased $276.92 worth of groceries while LPA was out facility. Fresh vegetables, fruits, meats, dairy, frozen items were supplied for the minimum of two day perishable foods and minimum of one week of nonperishable foods. POC cleared on 10/11/21.

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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC809 (FAS) - (06/04)

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