342700730-9-19-2023-27-AS-KHOS-CW3SN5-20230927140059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700730
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:08:17 AM

Substantiated

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
06/27/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20230627141211

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: 4	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Enele Ratumaitavuki		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Staff did not ensure that resident was adequately fed while in care.
Due to staff neglect, resident sustained pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Jamie Ivey Canady and Albert Johnson arrived unannounced to conclude the investigation of the above mentioned allegation(s) on 9/19/2023 at 9:00 am. LPAs were met by caregiver Enel Ratumaitavuki, and stated the purpose of today's visit.

The investigation was conducted by Department Investigations Branch. The investigation consisted of interviews with residents, interviews with staff, and review of resident medical reports, and files .

The Department has determined the following as it relates to the allegations: Staff did not ensure that resident was adequately fed while in care. Due to staff neglect, resident sustained pressure injuries while in care.

Cont on 9099-C

Substantiated

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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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 4

Control Number 27-AS-20230627141211

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: 09/19/2023

NARRATIVE

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According to page 1 of R1 Admission Agreement letter number (3) letter B number 5, 3 meals a day with doctor recommended dietary restrictions are included. "Special diets if prescribed by doctor". However, according to facility staff witness statements, R1 was not responding to eating and S1 did not seek a higher level of care. According to number 9 page 2 of R1 Admission Agreement, facility agreed to provide assistance with eating as part of the services the facility was to provide. Based on LPA review of facility files, facility Appraisal and Service plan demonstrates that R1 will need assistance with Acts of Daily Living (ADL) which includes eating. According to witness statements, interviews, medical and file reviews, facility did not provide services regarding eating as contractually agreed. Therefore, the allegation Staff did not ensure that resident was adequately fed while in care is Substantiated.
Based on observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Civil Penalties may be assessed at a later date.
Exit interview with facility staff Enele Ratumaitavuki. Appeal rights and report emailed due to printer malfunction.

Cont 9099-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20230627141211

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: 09/19/2023

NARRATIVE

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According to medical record review, R1 was in the Emergency Room (ER) on 6/8/2023, returned to the facility on 6/9/2023 and admitted to the hospital on 6/24/2023 with multiple stage 3 and 4 pressure injuries. According to staff interviews, facility file reviews and medical record review, R1 moved into the facility in September 2022 with no pressure injuries. According to facility record review, facility staff reported the beginnings of pressure wounds to S1. Based on medical record review and witness testimony, S1 did not seek appropriate medical care for R1 in a timely manner, resulting in the worsening of R1 medical condition. Therefore, the allegation Due to staff neglect, resident sustained pressure injuries while in is Substantiated.
Based on observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Civil Penalties will be accessed at a later date
Exit interview with facility staff Enele Ratumaitavuki Appeal rights and report emailed 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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20230627141211

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: 09/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/19/2023 Section Cited CCR 87464(f)(3)	1 2 3 4 5 6 7	87464(f)Basic services shall at a minimum include:(3)Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity, as specified in Section 87555, This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated she will perform staff training and provide training log in sheet to LPA via email No later than 9/20/2023
	8 9 10 11 12 13 14	According to staff interviews, facility file reviews and witness statements, the Licensee did not ensure resident received meals as prescribed by Title 22 regulations. This violation poses an imminent risk to residents in care.	8 9 10 11 12 13 14
Type A 09/19/2023 Section Cited CCR 87211(a)(B)	1 2 3 4 5 6 7	87211(a) Each licensee shall furnish to the licensing agency such reports...(B) Any serious injury as determined by the attending physician and occurring...this was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated she will perform staff training and provide training log in sheet to LPA via email No later than 9/20/2023
	8 9 10 11 12 13 14	Based on facility file review, medical record documentation and witness reports, it was discovered that resident sustained stage 3 and 4 pressure injuries while in facility care. This violation poses an immenent risk to residents in care.	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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