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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700440
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:23:01 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 CAREFACILITY NUMBER:
342700440
ADMINISTRATOR:NONU, JULIE ADRIANNAFACILITY TYPE:
740
ADDRESS:27 TRISTAN CIRTELEPHONE:
(916) 619-8590
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
10/14/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Atelaite PetiTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 10/14/21 at 4:00PM. LPA met with Atelaite Peti, Caregiver and stated the purpose of todays visit. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents.

LPA interviewed residents who were engaged in a group activity together in the backyard and in the common area.

LPA observed a posting of licensing reports; and a notice advising that an action is pending. LPA observed 6 residents and 1 caregiver during this visit.

The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 112.1 *F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.
LPA observed 2-day perishables and 7-day non-perishables.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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