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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700730
Report Date: 05/19/2021
Date Signed: 05/19/2021 04:36:02 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator Tuyet-Suong Teh
COMPLAINT CONTROL NUMBER: 27-AS-20210114130734
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: 0DATE:
05/19/2021
UNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Julie NonuTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility failed to report COVID outbreak.
Resident has multiple pressure injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Suong Teh and LPA Christina Valerio made subsequent complaint investigation on 05/19/21 to deliver the findings. Due to the facility is under construction and all 4 residents have temporary moved to Bella Villa 37 Mossglen Cir, Sacramento. CA. LPA met the facility administrator Julie Nonu at SomiSomi to deliver the findings..
During the investigation, the Department discovered from medical reports stated that Resident #1 (R1) was admitted to the Emergency Room (ER) on 01/01/21 with a diagnosis of Candidiasis/Cellulitis of penis. R1 was discharged back to the facility on the same day with antibiotics and topical cream. On 01/11/21, R1 was admitted to the ER. At the admission, R1 was tested for COVID-19 and the resulted was positive. It was discovered upon the exam six deep tissue pressure injuries were found Coccyx (Unstageable) skin non-blanchable dark discoloration, islands of full thickness skin open area on right sacrum; Right Hip intact skin with non-blanchable purple red discoloration; Right Heel intact skin with non-blanch deep purple discoloration; Right Lateral Ankle intact skin with non-blanchable purple-red coloration; Right Lateral Foot intact skin with non-blanchable purple-red discoloration; And Left Heel intact skin with non-blanchable dark purple discoloration.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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 5
Control Number 27-AS-20210114130734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ABOUNDING LOVE III
FACILITY NUMBER: 342700730
VISIT DATE: 05/19/2021
NARRATIVE
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On 04/14/21, the Department interviewed a former staff #1 (S1). S1 confirmed that she worked three to five consecutive days a week.. S1 stated that her duties consisted of cleaning the facility, preparing meals, changing client diapers, bathing, grooming clients, and dispensing their medications. S1 confirmed that she performed body checks on Resident #1 (R1) when she bathed him, two or three a week. S1 stated that she changed R1’s diaper four times a day and checked his diaper every two hours. S1 denied of observe any injuries on R1. S1 stated that she did not document client diaper changes because she was never instructed to document.

On 04/15/21, the Department interviewed the facility administrator Julie Nonu. Julie confirmed that staff are instructed to check for cuts or bruises when they are showering or changing client diapers. Julie confirmed that since R1 came back to the facility on 01/01/21, R1 was less mobile afterwards and would lay down and sleep a lot. Julie stated that she was not notify by any staff regarding of any bruises, cuts or open wounds on R1. On 01/16/21 LPA Suong Teh spoke to Julie and discovered that she learned from R1’s Responsible Party (RP) on 01/12/21 that R1 was positive tested for COVID-19. Julie admitted that she did not report to licensing within 24 hours.

On 04/15/21, the Department interview staff #2 (S2). S2 confirmed that Julie Nonu is his wife. R2 stated that he assigned to work at Abounding Love III two to three days a week and also “as needed” day or night. S2 confirmed that his duties consist of getting the clients up in the morning, bathing, and grooming, changing their diapers, preparing meals, and dispensing medications. S2 stated that he conducted daily body checks on all clients which documented as well as bathing and diaper changes. S2 did not recall ever observe R1 with any bruises or scars on his body.

Staff #3 (S3) refused the be interviewed by the Department. The Department was not able to contact Staff #4 and Staff #5.

Department observed R1’s on going notes from 01/02/2021 to 01/08/2021, R1’s diaper was reportedly changed 19 times and he was bathed once over six days, but no references were made of body checks conducted on R1.

Based on observation, interview, and record review, the resident sustained multiple pressure injuries while in care and licensee’s failure to report COVID-19 case to licensing within 24 hours. As a result of this investigation, Licensing has determined the above allegations is (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6, Chapter 8. At the time of the complaint investigation on (DATE), the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code § 1569.49.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210114130734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ABOUNDING LOVE III
FACILITY NUMBER: 342700730
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2021
Section Cited
CCR
87211(a)(2)
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87211(a)(2) Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Licensee/Administrator agree to read Regulation 87211, provide staff training on the regulation and provide a signed statement to CCLD that the regulation is understood along with documenation of training. Administrator also agrees to provide resident's family member with a copy of the LIC624 submitted to CCLD on 05/20/21.
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This requirement has not been met as evidenced by: Based on the Department interviews, the facility administrator Julie Nonu learned on 01/12/21 that R1 was positive tested for COVID-19. Julie admitted that she did not report to licensing within 24 hours. This violation poses an imminent risk to residents in care.
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Type A
05/20/2021
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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Licensee/Administrator agree to conduct staff training on appropriate reporting to resident's physician and family member following staff observing any changes in resident's condition. This includes updating the "Communication Record" to include notifying the physician, and providing training on the updated form. Documentation of training agenda/attendees to be provided to CCLD by fax by 05/20/21.
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When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidenced by: Based on the Department interviews and medical reports, Resident #1 (R1) was admitted to the hospital on 01/11/2021 with six deep tissue pressure injuries were found Coccyx (Unstageable), right hip, right heel, right lateral foot, right lateral ankle, and left heel. This violation poses an imminent risk to residents 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210114130734

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: DATE:
05/19/2021
UNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Julie NonuTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Resident is very underweight
Staff is not managing resident incontinence
INVESTIGATION FINDINGS:
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The Department conducted interviews and reviewed of R1’s records. On 01/01/2021, R1 first Emergency Room (ER) visit and the medical reports showed that he was weighted at 64kg. On 01/11/2021 R1 was admitted to the ER, the weight records showed estimated 64 kg. On 1/14/2021 another weight comment stated actual weight noted as 48.5 kg.
On 02/03/2021 the Department interviewed Witness #1 (W1). W1 stated that R1 moved from another assisted living to Abounding Love III in November 2020 to January 11, 2021. W1 stated that because of COVID-19 she did not see R1 often, but she saw R1 in November 2020 at Abounding Love III she was shocked to see his decline. On Medical reports dated 01/12/2021, W1 stated that she believed that R1 was eaten normally at the facility and W1 had been refusing food at the board and care.
On 04/12/2021 the Department interviewed witness #2 (W2). W2 stated that she provided geriatric house calls to patients who are unable to visit the doctor’s office. W2 confirmed that she visited R2 twice a month. However, toward the end of the year 2020 due to COVID -19, W2 stated that she was only able to see R2 about once a month. W2 stated that the last time she examined R1 was on 10/16/2020.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210114130734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ABOUNDING LOVE III
FACILITY NUMBER: 342700730
VISIT DATE: 05/19/2021
NARRATIVE
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W1 stated that she could not see R1 in person in November and December of 2020 due to COVID-19 restriction but was able to see him through “Facetime”. According to W2, R1 always appeared clean, well-groomed and taken care. W1 stated that R1 was always clean, and the house smelled clean. W2 stated that she was not shocked of how R1 appeared the last time she saw him in December 2020. W2 stated that patients who suffer from Alzheimer Dementia will deteriorate over time. W1 stated that if she has any concerns about the care R1 was received, as Mandated Reporter, R1 would have reported the conditions herself.

On 04/14/21, the Department interviewed a former staff #1 (S1). S1 stated that her duties consisted of cleaning the facility, preparing meals, changing client diapers, bathing, grooming clients, and dispensing their medications. S1 confirmed that on several occasions R1 would refuse to eat but S1 stated that she did not logged it.

On 04/15/21, the Department interviewed the facility administrator Julie Nonu. Julie confirmed that R1 was checked every couple of hours and changed four to five times a day. Julie stated that R1 was visited by Home Health about once every two weeks and the nurse and they did not have any concerns.

On 04/15/21, the Department interview staff #2 (S2). S2 stated that he conducted daily body checks on all clients which documented as well as bathing and diaper changes.

According to the doctor resident is very underweight and staff is not managing resident incontinence and resident is very underweight –. Based on interviews and records reviewed. The allegations are unsubstantiated.



A finding that the complaint allegation(s) is/are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5