342700827-5-28-2025-27-AS-SHUS-DH528M-20250528171033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 05/28/2025
Date Signed: 05/28/2025 05:10:51 PM

Document Has Been Signed on 05/28/2025 05:10 PM - 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 PEACE ELDERLY CARE		FACILITY NUMBER:	342700827
ADMINISTRATOR/ DIRECTOR:	WAQALALA, UNAISI		FACILITY TYPE:	740
ADDRESS:	7124 HAYWARD DR		TELEPHONE:	(916) 578-8834
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	05/28/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Una Waqalala		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

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On 5/28/2025 at 1:50 PM Licensing Program Analyst (LPA) Shakaricka Hughes conducted a case management deficiencies on the facility, based on observed deficiencies on a complaint investigation control number: 27-AS-20250313150435. LPA is addressing concerns on this case management for the following deficiencies:

Food locked in staff room:

On 3/19/2025 LPA Lee visited the facility to conduct a complaint investigation. During this visit it was learned that the 7-day non-perishable food supply was not stored in the kitchen area or accessible to residents in care. LPA Lee observed 7-day supply being stored in the staff’s room. LPA Lee advised the care staff that the refrigerator and pantry cannot be locked, as doing so would violate residents' personal rights. This observation was observed not in compliance with Title 22 regulations, Personal Rights of Residents in All Facilities section 87468.1(a)(2). Residents are to be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. Additionally, Residents should served food of the quality and quantity necessary to meet their nutritional needs. If food is locked away and inaccessible, healthful accommodations are not readily available to residents in care.

Continuation 809-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Shakaricka Hughes	TELEPHONE: (916) 764-1499
	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.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 PEACE ELDERLY CARE	FACILITY NUMBER: 342700827
	VISIT DATE: 05/28/2025

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Medication storage and discontinued medication:

On 3/19/2025 LPA Lee visited the facility to conduct a complaint investigation. During this visit LPA Lee observed medications for 4 out of 4 residents. Upon review of residents' medication boxes and Medication Administration Records (MAR) log, it was noted that R1 had one medication that was not documented on the MAR log, even though R1 has the medication in R1’s medication box and the medication was being administered to R1. Furthermore, it was observed that R3 had two discontinued medications in their medication box, with discontinuation dates of 01/01/25 and 03/11/25 (per care staff). The doctor's orders for the discontinued medications were not present in the resident’s file, and care staff could not locate the necessary documentation (MAR). The facility is not in compliance with Title 22 Incidental Medical and Dental Care Services 87465(6) in that R1’s medications were not recorded. Additionally, Title 22 Incidental Medical and Dental Care Services 87465(e) R3’s medications were not administered; the medications were discontinued and should’ve been properly destructed and documented as required.

An exit interview was conducted with the facility administrator Una Waqalala, and the following documents were provided to the facility LIC 809, LIC 809-C, were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Shakaricka Hughes	TELEPHONE: (916) 764-1499
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

LIC809 (FAS) - (06/04)

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