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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700499
Report Date:
12/12/2023
Date Signed:
12/12/2023 04:08:58 PM
Document Has Been Signed on
12/12/2023 04:08 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 II
FACILITY NUMBER:
342700499
ADMINISTRATOR:
NONU, JULIE
FACILITY TYPE:
740
ADDRESS:
3801 LAKE TERRACE DR
TELEPHONE:
(916) 547-0206
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95758
CAPACITY:
6
CENSUS:
DATE:
12/12/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
Julie Nonu
TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. 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.
LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3).
S2's file was not present at the facility. Nonu emailed LPA Moleski a copy of the file for review. S2's file contained a tuberculosis screening, but did not contain a health screening report.
S3's first aid certification is dated February 8, 2021. S3's first aid certificate states that it is only valid for two years, meaning the certification expired on February 8, 2023. S3 was listed on the facility's LIC 500 dated 7/31/23.
R4's file did not contain an LIC 602. Nonu said she gave the LIC 602 to R4's family.
LPA Moleski toured the facility with Dowe and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 115 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.
[continued on 809-C]
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
6
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:
12/12/2023
NARRATIVE
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LPA Moleski observed first aid supplies and smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.
LPA Moleski observed a fire extinguisher which last received annual maintenance on November 10, 2022. This fire extinguisher should have received annual maintenance prior to November 10, 2023.
LPA Moleski interviewed one staff member (S1) and one resident (R3).
This facility is being cited per the applicable 22 CCR Sections. An exit interview was conducted with Nonu. Appeal rights and a copy of this report was left with Dowe-Rose.
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
12/12/2023 04:08 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:
12/12/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not ensure that a fire extinguisher received annual maintenance as required, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/13/2023
Plan of Correction
1
2
3
4
Licensee agrees to either purchase a new fire extinguisher or procure maintenance services for the fire extinguisher. Licensee further agrees to send LPA Moleski a photograph of the new extinguisher, with a receipt, or proof of having procured annual maintenance services.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
12/12/2023 04:08 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:
12/12/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of S2's file, the licensee did not acquire and/or maintain on file a health screening for S2. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/26/2023
Plan of Correction
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2
3
4
Licensee agrees to acquire a health screening for S2 and send a copy to LPA Moleski.
vincent.moleski@dss.ca.gov
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
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
12/12/2023 04:08 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:
12/12/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not ensure S2's file was maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/26/2023
Plan of Correction
1
2
3
4
Licensee agrees to create a file for this employee at the facility containing all required components. Licensee further agrees to send LPA Moleski a photo of this file and its contents.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not ensure S3 maintained current first aid certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/26/2023
Plan of Correction
1
2
3
4
Licensee agrees to write a statement of acknowledgement of the requirement for staff to have current first aid certiifications. Licensee agrees to send this statement to LPA Moleski.
vincent.moleski@dss.ca.gov
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
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
12/12/2023 04:08 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:
12/12/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not ensure R4's complete file was maintained at the facility or a central administrative location, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/26/2023
Plan of Correction
1
2
3
4
Licensee agrees to acquire the missing documentation and place them in R4's file. Licensee agrees to send LPA Moleski a copy of the missing documentation.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
12/12/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/12/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6