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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 07/01/2021
Date Signed: 07/01/2021 10:38:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
342700827
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:7124 HAYWARD DRTELEPHONE:
(916) 578-8834
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator Unaisi WaqalalaTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 07/01/2021. LPA met with Unaisi Wagalala and explained the purpose of the visit. Unaisi Waqalala is the Administrator and holds certificate #60564441740 that expires on 06/30/23

This facility is a single story building licensed to serve six (6) non-ambulatory residents and has a waiver for 1 hospice. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 06/04/2021 Thermostat observed at (76.1) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed resident and staff files, including criminal record clearances. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.
The following forms were requested during today's visit on 07/01/2021:
LIC 308
LIC 500
Copy of Admin Certificate copy of control of property, copy of liability insurance.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited. Exit interview held with Unaisi Waqalala and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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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