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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700499
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:03:40 PM


Document Has Been Signed on 03/29/2024 12:03 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:NONU, JULIEFACILITY TYPE:
740
ADDRESS:3801 LAKE TERRACE DRTELEPHONE:
(916) 547-0206
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
03/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Latoya Dowe-RoseTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on a complaint investigation. LPA Moleski spoke with facility administrator Julie Nonu over the phone and explained the purpose of the visit. Nonu said staff member Latoya Dowe-Rose could sign this report in her absence.

During the course of the aforementioned complaint investigation, LPA Moleski learned of altercations between two residents (R1 and R2) on January 3, 2024, and January 16, 2024. Both incidents were witnessed by another resident (R3). A staff member (S1) observed injuries suffered by R1 and R2 after these altercations, and provided photos to LPA Moleski. These incidents were described in greater detail on the 9099 report delivered with the complaint findings.

LPA Moleski did not receive any incident reports regarding either of these incidents. This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Nonu. Appeal rights and a copy of this report were left with Dowe-Rose.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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 03/29/2024 12:03 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ABOUNDING LOVE II
FACILITY NUMBER: 342700499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2024
Section Cited
CCR
87211(a)(1)(D)

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“(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.”
This requirement was not met as evidenced by:
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Licensee agrees to provide a written statement to LPA Moleski asserting that incident reports shall be sent in as required in the future.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, two altercations occurred between residents and incident reports were not sent to CCLD, 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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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