<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:52:26 PM


Document Has Been Signed on 06/06/2022 03:52 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/06/2022 03:51 PM

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

NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA's) Ruth Wallace and Renee Campbell conducted an unannounced 1 Year Required Annual Inspection Visit.. LPA's met with Administrator and explained the purpose of the visit. Administrator Certificate #60564441740 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. There is 1 resident on hospice currently. LPA's toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA's observed the facility to be free of odor, clean and in good repair. LPA's observed sufficient furniture and lighting throughout the facility. In hospice resident room there was a lazy boy chair and wheelchair in front of exit door to outside. There are no bodies of water present.

LPA's 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. Smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers were serviced and expired 06/04/2022 Thermostat observed at (74.0) degrees Fahrenheit. LPA's observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA's reviewed (3) resident and staff files, including criminal record clearances. LPA's reviewed staff associations to the facility. First aid kit was checked and is complete.

The following documents to be submitted to CCL via email to LPA by 06/30/22:
LIC 308 - Designation of Administrative Responsibility, LIC 500 - Personnel Summary, LIC 610-E Emergency Disaster Plan, and Copy of liability insurance
Per California Code of Regulations, Title 22 Division 6, Chapter 8, two deficiencies were cited. Exit interview held with Administrator and a copy of reports/appeals given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/06/2022 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above in Fire Extinguishers tags expired on 6/4/2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
1
2
3
4
Licensee agreed to purchase fire extinguishers during annual inspection visit. LPA's observed new fir extinguishers purchased on 06/06/2022 and corrected by POC date. No further action required.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/06/2022 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's, the licensee did not comply with the section cited above in lazy boy chair and wheelchair in front of exit door to backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
1
2
3
4
LIcensee agrees to move lazyboy chair and wheelchair from front of exit door to backyard by POC Date of 6/8/22. Licensee removed lazy boy chair and wheelchair during the annual inspection visit on 6/6/22. LPA's observed moved furniture and no further action required.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3