342700827-4-13-2023-27-AS-KHOS-CR8H6U-20230425055543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700827
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:24:37 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
03/14/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230314151707

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: 5	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cleopatra Gardiner		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff did not meet resident's hygiene needs.
Facility staff did not respond to resident's calls for assistance.
Facility staff did not ensure that resident was adequately fed.
Facility staff did not adequately manage resident's medications.
Facility staff did not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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On 04/13/2023 at 9:00 am, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to deliver complaint findings. LPA Lee met with care staff Cleopatra Gardiner during today’s visit and toured the facility.
Throughout the course of this investigation, LPA Lee conducted staff and resident interviews, reviewed facility files, and reviewed medical documents. Based on the investigation findings three staffs reported there were no issues in providing care regarding resident’s hygiene needs, medication being administer, providing food services and responding to residents calls for assistance. LPA Lee interviewed six out of six residents and 5 of the 6 residents reported having no issues or concerns about the facility's care and supervision services. Furthermore, five out of six residents did not have complaints regarding the food service being served adequately and that their medications are given to the adequately. LPA Lee observed residents on 03/22/2023 and today’s visit and the residents appeared to be wearing clean clothing and appeared to be sanitary.

Continued LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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-20230314151707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE	FACILITY NUMBER: 342700827
	VISIT DATE: 04/13/2023

NARRATIVE

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LPA Lee reviewed MAR sheets and it was learned that residents are getting medications adequately. LPA Lee also reviewed clients care daily checklist log and learned that the logs are documented and complete. LPA Lee did not find a substantial preponderance of evidence to state that the facility did not ensure resident was adequately fed and that medication was adequately administered. Moreover, LPA Lee did not fine a substantial preponderance of evidence to state that the facility did not respond to residents calls for assistance and are not being treated with dignity and respect.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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