342700730-10-17-2023-27-AS-PLEE-CWPPJB-20231017112116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700730
Report Date: 10/17/2023
Date Signed: 10/17/2023 11:21:28 AM

Document Has Been Signed on 10/17/2023 11:21 AM - 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:	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:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Julie Nonu		TIME COMPLETED:	11:30 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 10/17/2023 at 8:28 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Enele Ratumaitavuki, who then called administrator, Julie Nonu. Administrator arrived approximately 15 minutes later. LPA Lee explained the purpose of the visit. Administrator and care staff Enele Ratumaitayuki assisted with today’s visit. Administrator certificate # is 6038867740 and will expire on 03/03/2024. The current census is 4 with 2 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for 2 hospice residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor and clean. LPA Lee observed the facility not in good repair. Resident room #3 is missing a window screen. Resident room #2 has a hole with exposed wires. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 11/17/2022. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 4 out of 4 medication administration record (MAR) and it was complete. First aid kit was checked, and it was complete. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: 10/17/2023

NARRATIVE

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LPA Lee requested resident and staff files for review. LPA Lee reviewed 4 out of 4 resident files and 2 out of 3 staff files and they were all complete. LPA Lee 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.

The following documents was provided to LPA Lee during today visit.

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

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) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/17/2023 11:21 AM - 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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)(1)

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The Licensee did not ensure that resident room #3 has a window screen, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee agrees to buy a window screen for resident room #3 window. Licensee will email LPA Lee at pang.lee@dss.ca.gov a picture of the resident room #3 with a new window screen. Licensee will also email copy of receipt of purchased of window screen. Licensee will also read and acknowledge regulation being cited and write a statement of acknowledgement. Licensee will send POC to LPA Lee by 10/24/2023 by 5:00 PM end of day.

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.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/17/2023 11:21 AM - 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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. Licensee did not ensure resident room #2 was in good repair. There's a hole in the wall with exposed wire, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to patched the hole in the wall by POC date 10/18/2023 by 5:00 PM by end of day. Licensee agrees to email LPA Lee at pang.lee@dss.ca.gov a picture of the hole in the wall patch up with no exposed wire by POC date 10/18/2023 by 5:00 PM end of day.

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.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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