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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700499
Report Date: 05/08/2023
Date Signed: 05/08/2023 04:35:13 PM


Document Has Been Signed on 05/08/2023 04:35 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 AC/SC, 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: 6DATE:
05/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Care staff - Atelaite PetiTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced for a case management visit. Moleski and Richardson met with care staff member Atelaite Peti, who called administrator Julie Nonu. Moleski and Richardson explained the purpose of the visit was to discuss a previous request for a new 602 for a resident (R1). Nonu said Peti was able to sign this report in her absence.

LPA Moleski conducted an annual inspection at this facility on 2/23/23. During the annual, LPA Moleski requested a new LIC 602 for R1. Nonu notified LPA Moleski via email on 2/24/23 that an appointment scheduled for 3/8/23 had been made for R1 for this purpose.

On 3/1/23, Nonu emailed LPA Moleski a LIC 602 dated 10/12/22 that had not been signed by R1 or R1's responsible person. On 3/3/23, LPA Moleski told Nonu that he would still like R1 to follow through with the appointment made for 3/8/23 in order to get a new LIC 602 for R1. On 3/3/23, Nonu said she would continue with the appointment and update LPA Moleski on progress.

On 3/14/23, LPA Moleski emailed Nonu to determine the status of the new LIC 602. Nonu emailed LPA Moleski to say that the appointment had been completed and that R1's responsible person still needed to return the LIC 602 to her. On 3/29/23, LPA Moleski called Nonu, to follow-up on the status of the new LIC 602. Nonu said R1's responsible person still needed to return the LIC 602 to her.

While speaking over the phone on 5/8/23, Nonu told LPA Moleski that R1's responsible person still needed to return the LIC 602 to her.

This facility is being cited per 22 CCR Section 87458(c). Appeal rights and a copy of this report were left with Peti.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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Document Has Been Signed on 05/08/2023 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ABOUNDING LOVE II
FACILITY NUMBER: 342700499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

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22 CCR Section 87458(c) - Medical Assessment: "The licensee shall obtain an updated medical assessment when required by the Department."

This requirement was not met based on LPA interviews with administrator Julie Nonu, and record review of R1's resident records, which poses a potential health and safety risk.
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Administrator Julie Nonu agrees to arrange a new, in-person medical appointment for R1 in order to acquire a new LIC 602 for R1. Nonu will email proof that this appointment has been made by Friday, May 12, 2023.

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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
LIC809 (FAS) - (06/04)
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