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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700730
Report Date: 04/23/2024
Date Signed: 04/23/2024 04:00:52 PM


Document Has Been Signed on 04/23/2024 04:00 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 IIIFACILITY NUMBER:
342700730
ADMINISTRATOR:NONU, JULIEFACILITY TYPE:
740
ADDRESS:5105 VILLAGE WOOD DRIVETELEPHONE:
(916) 547-0206
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
04/23/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Julie NonuTIME COMPLETED:
03:20 PM
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A Non-Compliance Conference (NCC) was conducted today on April 23, 2024, via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting to discuss compliance issues at the facility and the steps the facility is taking to address the Departments’ concerns. Present in the meeting is Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analysts (LPA) Pang Lee, Licensing Program Analysts Vincent Moleski, Ombudsman Suhair Siraj, Licensee Julie Noun, and licensing attorney Jacob Reinhardt. During this virtual meeting, the Non-Compliance Conference process was explained to the Licensee. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. The facility has previously received 17 Type A citations and 9 Type B citations since 09/19/2019.

Issues discussed during the meeting were:
· Following plan of operations
· Administrator Qualifications and Duties
· Follow Hospice Care Plan
· Incidental Medical and Dental Care Services
· Approve training through vendors with the department.
· Maintenance and Operations (Cockroaches)

· Building and Grounds (not in good repair)

· Eviction Procedures

· AWOL

Continued on LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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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 III
FACILITY NUMBER: 342700730
VISIT DATE: 04/23/2024
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· Reporting Requirements

· 911 Calls and alert medical for assistance

· Pre-appraisals and appraisals based on residents change of conditions.

· Residents and staff files incomplete

· Pressure Injuries

The facility has stated they will agree to do the following:

· Licensee agrees to put in place a written plan for residents repositioning and skin check. Written plan is due to the department by 05/03/2024.


· Licensee agrees to put in place a written log for building and grounds due to the department by 05/03/2024.
· Licensee agrees to put in place a written plan for round check on residents whereabouts due to the department by 05/03/2024.
· Licensee agrees to put in place a written plan for round checks on door alarms to ensure they are in good repair due to the department by 05/03/2024.
· Licensee agrees to put in place a written plan for when to call 911 due to the department by 05/03/2024.
· Licensee agrees to put in place an eviction template due to the department by 05/03/2024.
· Licensee agrees to put in place a designated smoking area for residents with an updated facility sketch due to the department by 05/03/2024.
· Licensee will send the department an updated LIC 500.

Notwithstanding the above statement, the Department will take the following actions:
· The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance.
· Facility designated Administrator and Licensee have agreed to enlist services from TSP. The Department will set up TSP services.

Failure to maintain substantial compliance outlined on the LIC 809 reported dated 04/23/2024 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action. The RO will revisit compliance in 9-12 months and begin the legal process if the facility is not in compliance. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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