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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700499
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:01:36 PM

Document Has Been Signed on 12/03/2024 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ABOUNDING LOVE IIFACILITY NUMBER:
342700499
ADMINISTRATOR/
DIRECTOR:		NONU, JULIEFACILITY TYPE:
740
ADDRESS:3801 LAKE TERRACE DRTELEPHONE:
(916) 547-0206
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Atelaite PetiTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a quarterly monitoring inspection. LPA Moleski met with staff member Atelaite Peti and explained the purpose of the visit. LPA Moleski contacted facility administrator Julie Nonu via telephone. Nonu said Peti could sign this report in her absence.

Upon arrival, LPAs Moleski and Williams knocked on the front door three times and waited a few minutes until Peti answered. Peti said she was assisting a resident (R4) in their room with medications. LPAs Moleski and Williams observed two plastic cups with several pills in each which were left unattended at the kitchen table. After answering the door and allowing LPAs Moleski and Williams inside, Peti left to continue assisting the resident (R4) in their room, leaving the pills out on the kitchen table unattended again. Peti removed the medications after this was brought to her attention by LPAs Moleski and Williams.

Upon arrival, LPAs Moleski and Williams observed a thermostat in the common area reading 64 degrees Fahrenheit, which is below the required minimum heated temperature of 68 degrees. Peti turned on the heater and the indoor temperature rose an appropriate amount during this visit.

LPA Moleski reviewed four resident files (R1-R4) and two staff files (S1-S2).

LPA Moleski toured the facility with Peti and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility's water temperature measured 107 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. During the tour, LPA Moleski observed a bottle full of laxative pills stored in an unlocked cabinet in a resident's (R3's) bathroom along with toothbrushes. In another resident's (R1's) room, LPA Moleski observed an antacid tablet on the floor.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 12/03/2024 12:01 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/03/2024 at 09:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING LOVE II
FACILITY NUMBER: 342700499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87303(b)(1)

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"(b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C)." This requirement was not met as evidenced by:
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Staff adjusted the thermostat during this visit. The temperature was raised to an appropriate level. This POC will be cleared.
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Based on observation, the main common area of the facility was not heated to a minimum of 68 degrees, which poses a potential health and safety risk.
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Type A
12/04/2024
Section Cited
CCR87465(h)(2)

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"(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement was not met as evidenced by:
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Staff removed the medications during this visit. Staff agreed to send LPA Moleski a photograph of a new refrigerated storage container by POC due date.
vincent.moleski@dss.ca.gov
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Based on observations, medications were left out in a common area, unlocked, while a staff member was busy elsewhere in the facility, which poses an immediate health and safety risk.
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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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ABOUNDING LOVE II
FACILITY NUMBER: 342700499
VISIT DATE: 12/03/2024
NARRATIVE
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While touring the kitchen, LPA Moleski observed a pair of scissors kept in an unlocked cabinet above the stovetop, and a sharp kitchen knife kept in an unlocked drawer along with other assorted utensils. Peti said she had been using the knife to cut fruit before LPAs Moleski and Williams arrived. In the refrigerator, LPA Moleski observed insulin needles stored in an unlocked container. Peti said she did not have the key. LPA Moleski observed dates written in black ink on the prescription labels of two of these needles. Peti said she had written the dates herself.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food.

This facility is hereby cited per 22 CCR Sections 87303(b)(1), 87465(h)(2), 87309(a), and 87465(h)(4). An exit interview was held with Peti. Appeal rights and a copy of this report were left with Peti.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 12/03/2024 12:01 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/03/2024 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING LOVE II
FACILITY NUMBER: 342700499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87309(a)

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"(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients." This requirement was not met as evidenced by:
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Staff locked up the offending objects during this visit. This POC will be cleared.
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Based on observation, a knife and a pair of scissors were left in unlocked storage space, which poses an immediate health and safety risk.
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Type B
12/10/2024
Section Cited
CCR87465(h)(4)

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"(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label." This requirement was not met as evidenced by:
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Staff agreed to have a statement of acknowledgement sent in by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation, prescription labels were altered by a staff person, which poses a potential health and safety risk.
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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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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