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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700730
Report Date: 12/15/2022
Date Signed: 12/15/2022 03:06:33 PM


Document Has Been Signed on 12/15/2022 03:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 6DATE:
12/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Epi DokonidaluTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived unannounced at the facility to conduct a case management visit due to pests observed at the facility on a previous visit. LPA Ivey Canady requested facility administrator be notified of today's visit. Caregiver contacted administrator. Administrator unable to attend today's visit due to flu illness. Administrator gave verbal permission for caregiver EPI Dokonidalu to sign for today's visit.

On 10/11/2022 LPA Ivey Canady toured the facility. As LPA Ivey Canady proceeded to set up a computer station, LPA Ivey Canady observed an adult size roach and 2 baby sized roaches on the table. LPA requested an area free of roaches and the caregiver replied there are roaches all over the facility. LPA Ivey Canady proceeded to conduct the remainder of the visit outside the facility.

On 12/15/2022 LPA Ivey Canady toured the facility. Upon arrival through the front door, LPA Ivey Canady proceeded to the kitchen area that appeared clean. LPA Ivey Canady observed approximately 3 or 4 roaches scattering across the kitchen counter while caregiver attempted to catch/kill the roaches with a wet paper towel. Based on LPA observation, facility is being cited under Title 22 regulations.


Per California Code of Regulations Title 22, Division 6 Chapter 8, deficiencies were observed and cited on form 809-D. Exit interview held and a copy of the report was emailed to Administrator Julie Nonu due to printer malfunction.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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Document Has Been Signed on 12/15/2022 03:06 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
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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited

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80087 Buildings and Grounds (a) the facility shall be clean, safe and sanitary....(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by:
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Licensee stated the facility is being treated for pests on a monthly and nightly basis. Licensee will provide LPA with invoices for pest control services via email or fax by 12/16/2022
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Based on LPA observations, the facility was infested with roaches. This poses an immediate health and safety risk to those 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: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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