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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:31:07 PM


Document Has Been Signed on 06/01/2023 04:31 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 AC/SC, 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:6; 6CENSUS: 4DATE:
06/01/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Charlene Saveligo and Cleopatra GardinerTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 06/02/2023 at 12:30 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with Charlene Saveligo, who stated that she is a caregiver. LPA Lee explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that were due 05/12/2023. During today's visit, LPA Lee asked to review residents and staff files and caregiver Charlene stated that she wanted LPA Lee to wait until the designation, caregiver Cleopatra Gardiner returns to the facility to answer and go over any questions that LPA Lee may have. Caregiver Charlene called caregiver Cleopatra and stated that caregiver Cleopatra will come to the facility shortly. LPA Lee toured and inspected the facility to ensure deficiency previously cited on 05/05/2023 have been corrected.

During today's visit, LPA Lee toured and inspected the facility. LPA Lee observed the main bathroom located in the hallway to be locked. Staff 1(S1) unlocked that bathroom and when asked by LPA Lee why the bathroom was locked (S1) stated that they locked the hallway bathroom because it is for the staff use only.
LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared; however it was learned that staff 1 (S1) is not associated to the facility.

Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 87303(c) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
2. Deficiency cited under Title 22 Regulation 87506(b)(10)) has not been cleared. Licensee did not complied with the terms of the POC by POC due date.
3. Deficiency cited under Title 22 Regulation 87411(c)(6) has not been cleared. Licensee did complied with the terms of the POC by POC due date.
Continued on LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/01/2023
NARRATIVE
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An immediate $500.00 civil penalty shall be assessed on June, 1, 2023; based on observation and review "Facility is not adhering to personnel requirements/background association of employees." Violation of California Code of Regulations Section 87411(g) was assessed on 06/01/2023 because the licensee did ensure that (S1) was associated to the facility prior to working.


As a result of this POC visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809, LIC 809-C reports, LIC 809-D page, LIC 421IM and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/01/2023 04:31 PM - 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
SACRAMENTO AC/SC, 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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2023
Section Cited
CCR
87355(e)(1)

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87355 (e)(1) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
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Effective immediately, the Licensee/ Administrator shall ensure that S1 does not work until fingerprint clearance and association is obtained. Licensee/Administrator shall also ensure that S1 obtains fingerprint clearance and association to the facility. Licensee/ Administrator shall send proof of fingerprint clearance and association to CCL
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This requirement is not met as evidenced by:
Based on today's POC visit LPA Lee learned that staff 1 was not associated to facility, however, S1 was present during today's visit and were caring for residents. This posed an immediate health and safety risk to residents in care
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prior to allowing S1 to work at this facility and shall send proof to CCL of S1's fingerprint clearance and association to LPA Lee by POC date 06/12/2023 by 5:00 PM. A Civil penalties have been assessed during today's visit.
Type A
06/05/2023
Section Cited
CCR87468.1(a)(3)

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87468.1(a)(3) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This posed an immediate health and safety risk to residents in care

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S1 unlocked the resident's main bathroom located in the hallway. LPA Lee informed S1 and S2 that the bathroom cannot be locked at any time.
All facility staff will review regulations pertaining to personal rights of residents in all facilities and write a statement acknowledging that all staff has read and understood the regulations.

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This requirement is not met as evidenced by:
Based on today's POC visit LPA Lee Observed resident hallway bathroom was locked. S1 unlocked the resident bathroom and stated that the bath was for staff only and that resident's bath is located in resident's bedroom 4's.
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Licensee/Administrator will emailed POC to LPA Lee by 06/09/2023 by 5:00 PM
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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/01/2023 04:31 PM - 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
SACRAMENTO AC/SC, 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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
87506(b)(10)

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87506(b)(10) Resident Records
(b) Each resident’s record shall contain at least the following information:
(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
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Licensee/Administrator will ensure R2 has a completed LIC 602. Licensee will ensure R4 has a completed Appraisal/Needs and Service Plan and LIC 613C. Licensee will email LPA Lee the completed documents.
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Based on record review, the licensee did not ensure 1 out of 4 resident's file had a completed LIC 602 and a TB Test. Licensee did not ensure 1 out of 4 resident's file had a completed Appraisal/Needs and Service Plan, LIC 613C Personal Rights which poses an immediate health, safety or personal rights risk to persons in care.
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 All staff will review regulations in regards to residents files and write a statement stating all staff have read and acknowledge the regulations. Licensee/Administrator will send POC to LPA Lee by POC due date 06/09/2023 by 5:00 PM.
Type B
06/09/2023
Section Cited
CCR87411(c)(6)

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87411(c)(6) Personal Requirement
(C) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training....
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records.....

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Licensee/Administrator will make sure S1 and S2 register for caregiver training and have their annual training completed. Licensee will ensure that staff trainings stays current. Licensee will review care staff training regulations and send LPA documents of completed trainings and a statement of the review regulations.
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Based on record review, the licensee did not ensure 2 out of 2 staff had their annual training records in staff files which poses an potential health, safety or personal rights risk to persons in care.
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Licensee/Administrator will send LPA copies of completed training's with training certificates to LPA Lee. All staff will review the regulations cited. Licensee/Administrator will write a statement stating that all staff have read and understood the regulations and email POC to LPA Lee by POC date 06/09/2023 by 5:00 PM.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4