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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 07/21/2020
Date Signed: 07/22/2020 07:44:17 PM

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 PEACE ELDERLY CAREFACILITY NUMBER:
342700827
ADMINISTRATOR:WAGALALA, UNAISIFACILITY TYPE:
740
ADDRESS:7124 HAYWARD DRTELEPHONE:
(916) 578-8834
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: DATE:
07/21/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Unaisi WagalalaTIME COMPLETED:
04:30 PM
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Announced Prelicensing visit made via Facetime out to this facility on 7/21/20 and was met by the Applicant, Unaisi Wagalala, who was briefly interviewed by LPA Jason Lund.

It was learned that this facility will be licensed to serve up to (6) residents at any given time. There were no residents in care during today's Prelicensing visit.

Tour of the facility was conducted via Facetime. Dining room, living room, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time.

Kitchen area was toured. Cabinets and drawers were opened and reviewed by LPA Lund along with the Applicant. The medication cabinet is also in the kitchen and locked. First aid kit was observed inside the medication cabinet and contained all required components at this time. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.

A tour of the facility had (4) private resident bedrooms, dining room, living room and (2) bathrooms. Furnishings and furniture intended for use by the residents were observed to be sufficient and able to degrees. There is one linen closet, located in the hallway, were it contained a meet the needs of the residents at this time. Hot water temperatures were taken and measured at (115) to make sure that they were within the allowed range of 105-120 sufficient supply of towels and linens able to meet the needs of the clients at this time.

A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time.

This facility has been found to be in compliance at this time.
Component 111 requirements were also done during the visit and completed.
Report will be emailed for signature and emailed back to LPA Lund
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2020
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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