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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700827
Report Date: 05/28/2025
Date Signed: 05/28/2025 05:02:37 PM

Substantiated


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
03/13/2025 and conducted by Evaluator Shakaricka Hughes
COMPLAINT CONTROL NUMBER: 27-AS-20250313150435
FACILITY NAME:ABOUNDING PEACE ELDERLY CAREFACILITY NUMBER:
342700827
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:7124 HAYWARD DRTELEPHONE:
(916) 578-8834
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Una WaqalalaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not provide adequate activities to residents in care
Staff did not ensure a first aid kit was maintained at the facility
Staff did not ensure resident records were properly maintained
INVESTIGATION FINDINGS:
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On 5/28/2025 at 1:45 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility administrator Una Waqalala and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5. A brief interview with conducted with Una Waqalala.

Allegation: Staff did not provide adequate activities to residents in care
It was alleged that; staff did not provide adequate activities to residents in care. This investigation is based on observations, and interviews. On 3/19/2025 LPA Lee conducted a visit to the facility, upon observation; no residents were observed participating in activities during the visit. LPA Lee observed four residents in the facility: Resident 1 (R1) was seen outside in the courtyard smoking before returning to their room to watch TV; (R2) was sitting on their bed with an iPad; and (R3) and 4 (R4) were out for a doctor's appointment and later returned to the facility for lunch.
Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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 8
Control Number 27-AS-20250313150435
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: 05/28/2025
NARRATIVE
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Allegation: Staff did not ensure resident records were properly maintained

It was alleged that staff did not ensure resident records were properly maintained. This investigation is based on observation of resident records. On 3/19/2025, LPA Lee conducted a facility visit and upon observation of 4 out of 4 resident files, and 2 of them were found to be incomplete. Both R3 and R4 had an LIC 625 Needs and Service Plan form in their files, but the document was not signed by both the administrator and the resident or their responsible party, and the form was blank. It was also observed that R3’s LIC 602 Physician’s Report was incorrectly placed in R1’s file. Resident records were observed not in compliance with Title 22 regulations Resident Records 87506(a). As resident records were observed not organized, and resident records were included in other resident files.

As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Una Waqalala and a copy of this report LIC 9099, LIC 9099-C, LIC 9099-D was provided, along with Appeal Rights and the LIC 811, the Confidential Names List.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20250313150435
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: 05/28/2025
NARRATIVE
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LPA Lee observed two designated areas for activities: one in the common area inside the TV stand and another in the dining area. Both areas were equipped with a variety of activities, including board games, puzzles, card games, books, painting supplies, markers, and crayons. On 5/06/2025 LPA Hughes and Lee conducted a follow-up visit to the facility, upon R5- was observed outside in the courtyard, R3- In bedroom watching television, R4- In bedroom in recliner sleeping, R2- In bedroom with a tablet watching television, R1 in bedroom sleeping. As stated in the facility program design, activities for residents include but are not limited to, resident’s assisting with meal preparation and grocery shopping, residents are also encouraged to socialize by offering opportunities to read aloud, participate in tea and office chats, ice cream socials and birthday parties. Watering plants, dancing, exercising and listening to music. On 5/28/2025 LPA Hughes, conducted interviews with 4 out of 4 residents, and concluded that no activities were being provided at the facility. Resident activites were observed as not in compliance with Title 22 regulations section 87219(a) as resident activities in the facility are not being planned or provided for residents in care.

Allegation: Staff did not ensure a first aid kit was maintained at the facility

It was alleged that staff did not ensure a first aid kit was maintained at the facility. This investigation is based on observation. On 3/19/2025, LPA Lee conducted a facility visit and upon observation a first aid kit was in the facility; however, the first aid manual was missing. This first aid kit was observed not in compliance with Title 22 regulations on Incidental Medical and Dental Care 87465(a)(8). As a first aid manual is a required component to be included with a first aid kit.

Continuation 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
03/13/2025 and conducted by Evaluator Shakaricka Hughes
COMPLAINT CONTROL NUMBER: 27-AS-20250313150435

FACILITY NAME:ABOUNDING PEACE ELDERLY CAREFACILITY NUMBER:
342700827
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:7124 HAYWARD DRTELEPHONE:
(916) 578-8834
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Una WaqalalaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not properly store resident's medication
Hazards were made available to residents in care
Staff obstructed facility emergency exits
Staff did not ensure sufficient healthy food items were made available at the facility for residents in care
Facility in disrepair
INVESTIGATION FINDINGS:
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On 5/28/2025 at 1:45 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility administrator Una Waqalala and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5. A brief interview with conducted with Una Waqalala.

Allegation: Staff did not properly store resident's medication
It was alleged that staff did not properly store resident’s medication. This investigation consisted of facility observation. On 3/19/2025 LPA Lee observed medications to be locked away and inaccessible to residents in care. On 05/06/2025 during a follow-up facility visit, LPA Hughes observed residents medications stored in a kitchen cabinet kept locked and inaccessible to residents. Based on observation this allegation could not be corroborated with any supporting evidence.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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 8
Control Number 27-AS-20250313150435
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: 05/28/2025
NARRATIVE
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Allegation: Hazards were made available to residents in care
It was alleged that hazards were made available to residents in care. This investigation consisted of facility observations, and interviews. On 3/19/2025 LPA Lee conducted a tour of the facility; no hazards were observed inside the building or in the courtyard. On 5/6/2025 LPA Hughes and Lee toured the facility for a follow-up visit and no hazards were made available to residents in care. Additionally, a phone interview with the reporting party (RP) revealed that no hazards were made available to residents in care, stating that this allegation was incorrect for this facility. Based on observation this allegation could not be corroborated with any supporting evidence.

Allegation: Staff obstructed facility emergency exits

It was alleged that staff obstructed facility emergency exits. This investigation consisted of facility observations and interviews. On 3/19/2025 LPA Lee conducted a tour of the facility; the emergency exit was not observed obstructed. However, it was observed that the emergency exit gates are not self-latching. On 5/06/2025 LPA Hughes and Lee conducted a follow-up facility visit; emergency exit located in the garage was not observed to be obstructed. Additionally, on 5/28/2025 LPA Hughes interviewed 4 out of 5 residents who did not observe any emergency exits being obstructed. 1 facility staff also denied observing facility emergency exits being obstructed. Based on observation, and interviews no corroborating evidence was identified upon examination of the allegation.

Allegation: Staff did not ensure sufficient healthy food items were made available at the facility for residents in care

It was alleged that staff did not ensure sufficient healthy food items were made available at the facility for residents in care. This investigation consisted of facility observation. On 3/19/2025 LPA Lee conducted a tour of the facility, upon observation the 2- day perishable food supply contained sufficient healthy food items made available to residents in care. On 5/28/2025 LPA Hughes, interviewed 4 out of 5 residents who are satisfied with the food being served in the facility. Based on observation, no corroborating evidence was identified upon examination of the allegation.

Continuation 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20250313150435
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: 05/28/2025
NARRATIVE
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Allegation: Facility in disrepair

It was alleged that; the facility is in despair, lights were inoperable. This investigation consisted of facility observations and interview. On 3/19/2025 LPA Lee conducted a tour of the facility; upon observation the facility was observed in good repair. On 5/6/2025 LPA Hughes and Lee conducted a follow-up facility visit, and observed the facilities resident bathroom, which was observed to be in good repair, lighting within the facility was observed operable and in good repair. Additionally, on 5/28/2025, LPA Hughes interviewed 4 out of 5 residents who had no concerns with the facility being in disrepair. Based on observation, and interviews conducted, no corroborating evidence was identified upon examination of the allegation.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. An Exit interview was conducted with XXXXX and a copy of this report LIC 9099, LIC 9099-C, LIC 9099-A was provided, along with Appeal Rights and the LIC 811, the Confidential Names List.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20250313150435
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2025
Section Cited
CCR
87465(a)(8)
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87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility...(8)If a facility has no medical unit on the ground a complete first aid kit shall be maintained and be readily available in a specific location in the facility.
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Licensee will ensure that the facility has a complete first aid kit with all required components including a first aid guide. Licensee will review regulations and provide
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This requirement was not met as evidenced by: the licensee did not ensure that the first aid kit was complete, including but not limited to a first aid guide.
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CCLD with a statement of acknowledgement and a photo receipt that a first aid guide was purchased for the facility by 06/04/2025.
Type B
06/04/2025
Section Cited
CCR
87506(a)
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87506(a)Resident Records.(a) The licensee shall ensure that a seperate, complete, and current record is maintained for each resident in the facility or in a central location readily available.... This requirement was not met as evidenced by:
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The licensee will ensure all resident records are kept organized and seperate. Additionally, licensee will review the regulations regarding Resident Records, and provide a statement of acknowledgement of the regulations by 06/04/2025.
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The Licensee did not ensure that resident records were properly maintained, organized, and resident files were kept seperate.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20250313150435
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2025
Section Cited
CCR
87219(a)
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87219(a)Planned activities. Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:(1) Socialization to promote or enhance personal relationships.
This requirement was not met as evidenced by:
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Licensee will ensure that planned activities are made available to the residents in care. Licensee will review Title 22 regulations regarding Planned activites and provide a statement of acknowledgement of the regulation by 06/04/2025.
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Licensee did not ensure that residents participation in planned acitvities were made available, as stated in the facility program design.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8