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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700730
Report Date: 08/23/2024
Date Signed: 09/06/2024 11:18:48 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240326145702
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: 5DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Ratumanoa NamusudrokaTIME COMPLETED:
01:41 PM
ALLEGATION(S):
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9
Facility staff failed to provide appropriate care to a resident resulting in death.
Staff did not ensure a resident attended a scheduled medical appointment.
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT CREATED ON 07/23/2024.

On 08/23/2024 at 12:10 PM, Licensing Program Analysst (LPAs) Pang Lee and Holly William arrived unannounced to this facility to conduct a complaint visit. LPAs met with care giver Ratumanoa Namusudroka and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. Caregiver called administrator Julie Nonu to informed that CCLD is present in the home. A brief interview was conducted with via telephone with the administrator. The current census is 5.

Allegation: Facility staff failed to provide appropriate care to a resident resulting in death.
It was alleged that facility staff failed to provide inappropriate care to a resident resulting in death. This investigation consisted of records reviewed, interviews with staff, residents, a nurse practitioner. Based on resident 1 (R1)’s death certificate it was listed that (R1)’s causes of death were Acute Hypoxic Respiratory Failure Syncytial Virus (RSV).

Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240326145702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/23/2024
NARRATIVE
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THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT CREATED ON 07/23/2024.

Based on facility staff interviews on 01/10/2024, (R1) went to the bathroom and slid out of (R1)’s wheelchair or off the toilet. Facility staff contacted Alpha One to help lift (R1) and transport (R1) to the ER, but (R1) refused to go. (R1) was then transferred back into (R1)’s bed. Based on Alpha One document it was noted that (R1) refused to be transported and was document dated on 01/10/2024. Both (S1) and administrator stated that they never saw any signs or symptoms of (R1) being sick while at the facility.

Based on (R1)’s Nurse Practitioner (NP), (NP) stated that she/he does not believe the facility staff could have done anything to prevent (R1) from getting (RSV). (NP) believes there was nothing the facility could have done to help (R1) survive the virus and that it would not have made a difference if (R1) was sent to the hospital sooner. (NP) last saw (R1) was on 01/10/2024 and that (R1) “seemed fine” and that (R1) numbers/vitals call came back good. Based on the other residents who also lived in the home did not disclose any serious complaints or concerns regarding living in the facility.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED.

Allegations: staff did not ensure a resident attended a scheduled medical appointment.

It was alleged that staff did not ensure a resident attended a scheduled medical appointment This investigation consisted of records reviewed, interviews with staffs, residents, and (R1)’s Nurse Practitioner (NP). Based on records review there were no evidence and documentation that (R1) had an appointment on 01/12/2024. Based on facility staff interview (S1) and (S2) did not know anything about (R1) having a scheduled medical appointment on 01/12/2024. Moreover, based on interview with (R1)’s Nurse Practitioner (R1) did not have a scheduled appointment on 01/12/2024.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240326145702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/23/2024
NARRATIVE
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THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT CREATED ON 07/23/2024.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3