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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700730
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:15:57 AM


Document Has Been Signed on 09/06/2024 11:15 AM - 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: 4DATE:
09/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Julie Nonu and Ratu Manoa QereaTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on a quarterly visits due to non-compliance concerns discussed during an office meeting on 04/23/2024. LPA Lee met with care giver Ratu Manoa Qerea who then notified administrator Julie Nonu that CCLD were present in the home. Approximately 20 minutes later administrator arrived and joined the visit. LPA Lee explained the purpose of the visit. The census is 5 with 1 facility staff.

LPA Lee and care staff Ratu Manoa toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 5 resident bedrooms, 2 resident bathrooms, common area, staff room, smoking area, kitchen, laundry room, garage, and the courtyard. LPA Lee observed resident bedrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. It was observed resident bedroom #1 had a hole that measured approximately 6 inches on the wall by the resident’s bed. Bathrooms handrails and non-skid mats are in good repair. Hot water temperature was measured at 106.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were up to date and fully charge. No emergency exits were obstructed. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply and it were sufficient. LPA Lee observed the pantry locked and made inaccessible to residents. Per administrator, the pantry is locked at night due to a resident who is diabetic and likes to eat sweets. LPA Lee observed the laundry room where it was observed that detergent, and all cleaning supplies were locked and made inaccessible to residents at this time. Knives were observed to be locked and made inaccessible. First aid kit was checked and it is complete.

LPA requested to review 3 resident files and 2 staff files. Staff files and resident files were observed to be current with up-to-date. LPA Lee reviewed 3 resident medications and it was up to accurate and complete.

As a result of this visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were 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: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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 2


Document Has Been Signed on 09/06/2024 11:15 AM - 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 III

FACILITY NUMBER: 342700730

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Licensee agrees to patch the hole on the wall by POC date 09/13/2024 by 5:00 PM by end of day. Licensee agrees to email LPA Lee at pang.lee@dss.ca.gov a picture of the hole on the wall patch up.
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Based on observation and interview, the licensee did not comply with the section cited above. Licensee did not ensure resident room #1 was in good repair. There's a hole next to resident's bed which poses an immediate health, safety, or personal rights risk to persons in care.
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Type B
09/06/2024
Section Cited
HSC1569.269(a)(5)

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1569.269 Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
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Administrator unlock the pantry during today’s visit. Administrator agrees to ensure that the pantry closet where snacks are kept is unlock for the residents. Administrator will read the regulation cited and provide a written statement acknowledging understanding of the regulation. POC will be provided to LPA Lee by 09/13/2024 by end of day 5:00 PM.
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Based on observation and interview the licensee did not comply with the section cited above. LPA observed the facility pantry locked were not accessible to resident in care, which poses a potential health, safety, or personal rights risk to persons in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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