342700730-3-21-2023-27-AS-KHOS-CQKMFD-20230404093411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700730
Report Date: 03/21/2023
Date Signed: 03/21/2023 02:46:54 PM

Unsubstantiated

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
12/06/2022 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20221206100301

FACILITY NAME:	ABOUNDING LOVE III		FACILITY NUMBER:	342700730
ADMINISTRATOR:	NONU, JULIE		FACILITY TYPE:	740
ADDRESS:	5105 VILLAGE WOOD DRIVE		TELEPHONE:	(916) 547-0206
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 6	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Epi Dokonidalu		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are retaining a resident that requires a higher level of care
Staff did not ensure that resident diabetes was adequately managed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findnigs. LPA met with Epi Dokonidulu who contacted administrator Julie Nonu. Julie authorized Epi to sign for today's visit.

The investigation consisted of interviews with residents, interviews with staff, interview with witness, review of resident files, chart notes and physician reports.

The Department has determined the following as it relates to the allegations: Staff are retaining a resident that requires a higher level of care, and Staff did not ensure that resident diabetes was adequately managed

Continued on LIC 9099 - C...
Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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-20221206100301

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: 03/21/2023

NARRATIVE

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On 3/02/2023 and 12/19/2022 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted interviews and record review regarding current allegations. According to record review, facility conducted a pre-appraisal for R1 on 2/09/2021. Based on physician's report records review, R1 has been diagnosed with Diabetes Mellitus. According to review of pre-placement appraisal, diabetes is listed in health conditions and resident is ambulatory. Based on record review, R1 requires help with medical management and based on interviews, chart reviews and physician record review, facility is providing R1 assistance with medicinal management. According to Title 22 regulations, facility is providing care to resident in alignment with resident diagnosis. According to Physician's report, R1 is not confused or disoriented, able to communicate needs and leave the facility unassisted. In accordance with record and document review, R1 is receiving services and level of care for level of care resident requires. Therefore, the allegation Staff are retaining a resident that requires a higher level of care is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 3/02/2023 and 12/19/2022 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted interviews regarding current allegations. According to interview with Staff 1 (S1), R1 is the only resident in the facility diagnosed with diabetes. Based on interviews with R1, facility staff does help R1 with insulin by checking R1 glucose reading after R1 tests self. After checking R1 reading, facility staff ensures R1 medication is administered in the correct quantity. According to interview with R1, S1 and Staff 2 (S2), there has not been a time where R1 refused to take prescribed medication. According to Admission Agreement for R1, R1 is able to administer own prescription medications. Based on interview with R1, R1 last doctor visit was the week of 2/28/2023. R1 was transported to the doctor's visit via R1 family. According to record request and record review, facility does not
Cont pg 2 of 3

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20221206100301

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: 03/21/2023

NARRATIVE

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have an electronic automated charting system regarding residents with diabetes. However, LPA obtained chart notes from the facility regarding tracking diabetic information. According to record review, facility has charted daily insulin intake with amounts recorded for each day. Therefore, regarding the allegation Staff did not ensure that resident diabetes was adequately managed is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report has been given via email due to printer malfunction.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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
12/06/2022 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20221206100301

FACILITY NAME:	ABOUNDING LOVE III		FACILITY NUMBER:	342700730
ADMINISTRATOR:	NONU, JULIE		FACILITY TYPE:	740
ADDRESS:	5105 VILLAGE WOOD DRIVE		TELEPHONE:	(916) 547-0206
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 6	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Epi Dokonidalu		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff obtained a personal loan from resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findnigs. LPA met with Epi Dokonidulu who contacted administrator Julie Nonu. Julie authorized Epi to sign for today's visit.

The investigation consisted of interviews with residents, interviews with staff, interview with witness, review of resident files, chart notes and physician reports.

The Department has determined the following as it relates to the allegations: Staff obtained a personal loan from resident in care

Continued on LIC 9099 - C...
Page 1 of 2

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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-20221206100301

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: 03/21/2023

NARRATIVE

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On 3/02/2023 and 12/19/2022 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted interviews regarding current allegations. Based on interview with S1, there was no facility knowledge of a loan being given to a staff member or a person outside of the facility. According to interview with R1, there was not a loan given to a staff member of the facility. R1 stated there was a loan given to the person who is in a relationship with R1 that does not reside in the facility. R1 stated there is nothing in writing regarding the loan. R1 stated the partner received a loan of $2500 and has paid back $1000 and now owes $1500. R1 stated the partner pays R1 back $100 each month. R1 stated the relationship with partner is not monitored by facility staff, because R1 does have personal rights. According to interviews with S1 and S2, the partner does visit the facility on a regular basis and R1 and the partner sit at the table. Based on interview with S1, and record review, S1 has documented via Admission Agreement that residents do not hold more than $100 in the facility at any time. Based on record review, facility form LIC400 dated 10/16/2019, is marked such that the facility will not be handling client cash resources. According to record review R1 has not been diagnosed with dementia. Therefore, the allegation Staff obtained a personal loan from resident in care is Unfounded.
Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview held, and a copy of this report has been given via email due to printer malfunction.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5