342700827-6-3-2021-27-AS-SRIN-C422QC-20210615173542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700827
Report Date: 06/03/2021
Date Signed: 06/03/2021 02:55:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2020 and conducted by Evaluator Tuyet-Suong Teh

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201005120708

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:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Noami Natua		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not supervising resident in care.
There are uncleared adults staying at the facility.
The facility yard is littered with debris.
The facility has an odor.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Suong Teh and LPA Christina Valerio made subsequent complaint investigation on 06/03/2021 to deliver the findings. LPA spoke to staff Noami Natua, and explained the purpose of the visit.
On 10/06/2020 the Department interviewed the reporting party (RP). RP stated that there was a resident coming and leaving the facility all hours of the evening and days. RP stated that there is no supervision at the home. RP stated that there might be uncleared adults resided at the facility. RP stated that the facility yard was littered with food trash and debris.
On 05/11/2021 the Department interviewed witness #1 (W1). W1 verified that she has lived in the neighborhood for approximately thirty years. W1 stated that was never any problems before and the noise level was significantly lower. W1 stated that when facility reopened around six or eight months ago, the noise began. W1 stated a man who claimed to be a resident at the home. W1 believed that the resident owned his own vehicle. W1 stated that several neighbors called the police on the resident because of him littering and his attitude. W1 stated that the resident also approached several neighbors late at night, knocking on their doors. W1 confirmed that resident is no longer reside at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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-20201005120708

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700827
	VISIT DATE: 06/03/2021

NARRATIVE

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On 05/11/2021 the Department interviewed witness #2 (W2). W2 confirmed to live in the neighborhood for a long time, she and her husband are now retired. She stated there appears to be younger residents other than elderly next door. W2 stated that he people at the facility appeared to smoke in the facility backyard which blows over into her yard. W2 stated that it is hard for her to enjoy being in the yard with the smoking, cussing, and loud talking from the residents at the facility.

On 05/11/2021 LPA Ruth Wallace arrived at the facility @9:20 am. LPA Wallace reviewed staff and resident files. Staff had current First Aid/CPR certificates, all were fingerprint cleared, and had documentation for training in files. The front and backyard observed to be manicured, trimmed trees, flowers, lawn was cut, and there was no debris on property. The resident rooms were clean, bathrooms clean, kitchen had plenty of food in refrigerator and pantry, and no odor in the house. The laundry room was locked where chemicals are kept. The garage had furniture in it that is going to be removed soon; There was still the ability to use as an exit if there was an emergency. No one was living in the garage.

LPA Wallace observed that facility patio is used for smoking and observed several residents were smoking. While LPA Wallace was at facility, it was observed the residents were using profanity language and talking loudly. LPA Wallace asked about the trailer to staff #1(S1) and stated the utility trailer was placed to haul off old furniture or items that need to go to the dump. Presently it was not at the facility. LPA Wallace asked about previous male residents, S1 stated they were only temporary and again had primary medical diagnosis. LPA Wallace suggested to S1 that he discussed to residents about foul language, volume of voices, and remind them there are neighbors on all sides of house.

Based on interviews and records reviewed. The allegations are unsubstantiated. A finding that the complaint allegation(s) is/are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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