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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700499
Report Date: 10/18/2021
Date Signed: 10/18/2021 12:00:03 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 IIFACILITY NUMBER:
342700499
ADMINISTRATOR:NONU, JULIEFACILITY TYPE:
740
ADDRESS:3801 LAKE TERRACE DRTELEPHONE:
(916) 547-0206
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
10/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aliti WaqalalaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 10/18/2021 at 11:30am to inquire if there is an excluded person presently working in the facility. LPA met with Aliti Waqalala, Designated person in charge and stated the purpose of the visit which is due to a Decision and Order effective 10/18/21.

LPA spoke with Julie Nonu regarding a person that should be excluded from licensed facilities. Julie Nonu stated that the person has not been working at the facility since July 17, 2021. Julie Nonu requested that Aliti Waqalala sign report and be given the documents for todays visit.

To date, LPA found that the person in question is still associated to the facility according to a facility roster dated 10/15/21. The Administrator shall remove the person's association from the facility as of todays date.

LPA provided Aliti Waqalala with a copy of the Order to Individual of Immediate Exclusion From All Facilities. LPA informed Aliti Waqalala and Julie Nonu this person is not allowed to be employed and/or on the facility premises.

The Order to Individual of Immediate Exclusion From All Facilities came into effect as of 10/18/2021.

The facility understands this is an Immediate Exclusion and has agreed this person cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited. Exit interview held, A Copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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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