342700827-4-2-2024-27-AS-KHOS-D47JF5-20240410070009

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700827
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:29:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2024 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20240207141252

FACILITY NAME:	ABOUNDING PEACE ELDERLY CARE		FACILITY NUMBER:	342700827
ADMINISTRATOR:	WAQALALA, UNAISI		FACILITY TYPE:	740
ADDRESS:	7124 HAYWARD DR		TELEPHONE:	(916) 578-8834
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 6	DATE:	04/02/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Unaisi Waqalala		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff locked resident out of the facility
Resident does not receive proper medication assistance

INVESTIGATION FINDINGS:

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On 4/2/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to complete and delivery findings for a complaint investigation received on 2/7/24. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Regarding allegation, Staff locked resident out of the facility, Resident does not receive proper medication assistance, the investigation revealed that no preponderance of evidence was observed or obtained to substantiate the facility failed to uphold resident rights and provide appropriate care and supervision. Based on resident interviews, 4 out of 6 residents stated that they were not aware of any resident being locked out of the facility and that they all received their medications timely. Staff S1 denied locking any clients out of the care home.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240207141252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PEACE ELDERLY CARE	FACILITY NUMBER: 342700827
	VISIT DATE: 04/02/2024

NARRATIVE

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As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, copy of report provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC9099 (FAS) - (06/04)

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