342700730-12-3-2024-27-AS-PLEE-DBLRLJ-20241203120712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700730
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:07:19 PM

Document Has Been Signed on 12/03/2024 12:07 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 III		FACILITY NUMBER:	342700730
ADMINISTRATOR/ DIRECTOR:	NONU, JULIE		FACILITY TYPE:	740
ADDRESS:	5105 VILLAGE WOOD DRIVE		TELEPHONE:	(916) 547-0206
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:44 AM
MET WITH:	Ratumanoa Namusudroka		TIME VISIT/ INSPECTION COMPLETED:	11:41 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 012/03/2024, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with direct care staff, Ratumanoa Namusudroka and explained the purpose of the visit. Direct care staff text administrator Julie Nonu to informed that CCLD was present in the home. At 9:20 AM, LPA received a text message from administrator stating that she is not able to join the inspection and that care staff Ratumanoa can assist with today’s visit. Administrator certificate # is 7011453740 and will expire on 04/04/2025. The current census is 6 with 1 facility staff. This facility is a single story building licensed to six (6) non-ambulatory residents and approved for 2 hospice residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, garage and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed the facility had sufficient seven day non-perishable food supplies and two day perishable food supplies at this time. Hot water temperature was measured at 114.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 11/27/2024. LPA observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat observed at 80 degrees Fahrenheit. LPA observed toxins located in the garage and kept locked and inaccessible to residents. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 4 out of 6 medication administration record (MAR) along with residents’ medications and it was not complete. Continued LIC 809-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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: 12/03/2024

NARRATIVE

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It was observed that R1 had two ointment medications that are in R1’s medication box; however, it was not on R1’s MAR log. It is unclear if the medications were administered to residents as prescribed. The first aid kit was checked, and it was complete. LPA requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and 2 staff files and they were complete. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

As a result of this annual 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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/03/2024 12:07 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 III	FACILITY NUMBER: 342700730
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the administrator did not comply with the section cited above. Administrator did not ensure the residents Medication Administrator Record was completed to reflect the medication that was . Care staff in R1's medication box. Care staff, Ratumanoa Namusudroka stated that he forgot to add the two ointment medication to R1's MAR Log and stated that R1 did received the medication. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2024
	Plan of Correction
1 2 3 4	Facility Administrator will review the section, 87465(d)(3). A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA’s email at pang.lee@dss.ca.gov by the due date of 12/13/2024 COB at 5:00pm. Information submitted must include. Attendees, trainers, and information discussed.

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.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3