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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700730
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:26:05 AM

Substantiated


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:
09/06/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julie NonuTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff did not meet a resident's diabetic needs.
INVESTIGATION FINDINGS:
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On 09/06/2024 at 11:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Julie Nonu and explained the purpose of the visit. The purpose of this visit is to amend a complaint finding that was delivered on 08/23/2024. The current census is 5.

Allegation: Staff did not meet a resident's diabetic needs
It was alleged that staff did not meet a resident’s diabetic needs. This investigation consisted of records reviewed and interviews with staff. Based on (R1)’s LIC 602 Physician’s report it stated that (R1)’s on a special diet and cannot have peanuts. Based on (R1)’s LIC 603A Resident Appraisal dated on 01/01/2024, (R1) was listed as diabetic-noninsulin dependent and special diet of food intake was listed as “limited sugar.” Moreover, on (R1)’s Physician’s order dated on 01/01/2024, (R1)’s diet was listed a “diabetic low sodium salt diet”.
Continued LIC 9099-C
Substantiated
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: 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.
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: 09/06/2024
NARRATIVE
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Based on staff interviews staff were not aware that (R1) required a diabetic diet even though it was on (R1)’s physician’s order that the (R1) needed a low sodium diet. Moreover, staff were not aware that (R1) had a special diet of limited sugar per (R1)’s LIC 603A Resident Appraisal. It was also learned on 03/28/2024 by staff (S1) that (S1) was not aware that (R1) has a special diet and cannot have peanuts. (S1) admitted to feeding (R1) peanut butter sandwich for meals.

As a result, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was given 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement was not met as evidence by:
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Licensee stated she will ensure that when a resident is admitted to the care home all health documents are reviewed by all staff and are understood what the residents’ needs are. Licensee also stated she will perform staff training of General Food Service Requirement and provide training materials used and training sign in sheet to LPA via email No later than 9/13/2024.
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Based on file review and interviews, the administrator did not ensure that (R1)’s special diet needs were being met. This poses/posed an immediate 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3