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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 07/17/2026
Date Signed: 07/17/2026 04:20:56 PM

Document Has Been Signed on 07/17/2026 04:20 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 CAREFACILITY NUMBER:
342700827
ADMINISTRATOR/
DIRECTOR:		WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:7124 HAYWARD DRTELEPHONE:
(916) 578-8834
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
07/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Shanice DownerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On July 17, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct the annual inspection visit. LPA initially met with staff on duty, Shanice Downer (S1), and stated the purpose of the visit. The Administrator, Unaisi Waqalala (AD) was notified. AD is unable to be present during this visit. Per LIC500 dated June 6, 2026, AD is not scheduled today. Present during this visit were six (6) residents in care with one (1) staff on duty (S1).
Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory. Facility currently has a hospice waiver for one. Facility does not have clearance for bedridden, delayed egress and locked interior/exterior parameter.
Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. The following were observed during inspection:
  • The fire door was propped open with a door stopper during this visit (photo taken).
  • The ceiling vent located in the hallway was full of dust that had accumulated (photo taken).
  • For the exit side gate located left of the facility, it is equipped with the slide bolt lock or barrel bolt. This lock is located at the top of the gate where someone who is wheelchair bound would not be able to reach. Additionally, when this LPA attempted to unlock, it required LPA to lift the gate a little in order to slide the lock open. This may be difficult for some of their residents to open. This lock and how difficult it is to unlock is not appropriate in residential facilities (photo taken).
  • The other side gate (bigger gate), LPA observed that it is not level to the latch so it cannot be properly locked. Additionally, LPA attempted to swing it open, and it requires a bit of a force to swing it open. Additionally, this gate is not equipped with a handle for residents to pull. The placement of the lock is also at the top of the gate where a resident who is a wheelchair bound may not be able to reach (photo taken).
{1 of 2}
Stephen Richardson
Arvin Villanueva
DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2026
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: 07/17/2026
NARRATIVE
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Record Reviews: LPA reviewed three (3) staff files, six (6) resident files, and facility records.
  • Review of resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, and Ambulatory Status. LPA reviewed 2 of 4 resident medications. Per review, 6 of 6 residents did not have PRN Authorization Letters completed. At least one resident (R6) had inaccurate Medical Assessment (LIC602A). This was observed cooking in an oven from previous visit, smoking cigarette from previous visits and during this visit, and washing dishes during this visit. Per staff interview, R6 is able to independently shower and access hygiene items. Per review of LIC602A, R6 was assessed to be at risk if they have access to these items or near heating devices.
  • Review staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial Training. AD's administrator certificate expired on July 8, 2026. Per review of this website on this day: https://www.cdss.ca.gov/inforesources/community-care/administrator-certification/administrator-information/active-certificates - the administrator was not listed in the “active certificates list”; but rather it was listed in the “pending renewal applications” where application was received on July 8, 2026. At this time, the administrator's certificate is not current.
  • Review of fire drill/disaster drill records: facility conducts quarterly drills and last drill was conducted on July 1, 2026.
  • Review of the Infection Control Plan and Emergency Procedure Plan, annual review was not conducted based on the lack of documentation or signature. Advisory was provided to update their Emergency Procedure Plan to include their exits.
Documents Requested: LPA requested a copy of current LIC500, LIC308 and updated Liability Insurance Certificate and Emergency Procedure Disaster Plan to be emailed at arvin.villanueva@dss.ca.gov
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited. Immediate Civil Penalty is being assessed today in the amount of $500 based on fire safety violation. Advisories were also provided.
Exit interview was conducted. A copy of the report was provided upon exit.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2026 04:20 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/17/2026 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE
FACILITY NUMBER: 342700827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 6 of 6 residents do not have documentation that document their capability to communicate their need for PRN medication. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Per discussion, Administrator will submit a copy of each resident's PRN authorization letter signed by their physician by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2026 04:20 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/17/2026 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE
FACILITY NUMBER: 342700827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. The administrator's certificate expired on 7/18/2026 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Per discussion, the administrator will submit a copy of their current administrator certificate to the department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2026 04:20 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/17/2026 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE
FACILITY NUMBER: 342700827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the fire door to be propped opened during this visit. Additionally, one of the exit gate did not have a single-action gate latch. LPA had to lift the gate and slide the lock to open. This lock is also located at the top of the gate which someone who is wheelchair-bound would not be able to unlock immediately in an emergency. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2026
Plan of Correction
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Per discussion, the licensee will change the lock for the side exit gate and send a photo evidence to the Department by POC due date.
During this visit, staff on duty closed the fire door.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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