342700827-5-5-2023-27-AS-PLEE-CRJQTV-20230505122743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700827
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:27:51 PM

Document Has Been Signed on 05/05/2023 12:27 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 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: 3	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Cleopatra Gardiner		TIME COMPLETED:	12:40 PM

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 Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection on 05/05/2023 at 8:35 AM. LPA Lee met with care staff Cleopatra Gardiner and explained the purpose of the visit. Care staff assisted with today’s visit. The census today is three (3). LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has one public telephone one in the common area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve six (6) non-ambulatory residents with one (1) hospice waiver. LPA observed the facility to be free of odor and clean. LPA observed three (3) resident's bedroom missing window screens. LPA also observed two (2) windows in the kitchen missing window screens. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. The resident bathroom water temperature measured at 114.6 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Fire extinguisher was last serviced on 05/01/2023. Facility thermostat observed at 70 degrees Fahrenheit. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed 4 out of 4 resident medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA requested resident and staff files for review. LPA reviewed 4 out of 4 resident files and 2 out of 4 resident files were not complete. LPA reviewed 2 out of 2 staff files and 2 out of 2 staff files were not complete. 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 and associated to the facility. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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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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: 05/05/2023

NARRATIVE

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The following documents will be email to LPA Lee during by 05/12/2023 by 5:00 PM business hour:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Proof of Current Liability Insurance
(4) LIC 610 Emergency Disaster Plan

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided 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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2023 12:27 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: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

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:
	Deficient Practice Statement
1 2 3 4	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 comepleted Appraisal/Needs and Service Plan, LIC 613C Personal Rights which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee 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. Licensee review regulations in regards to residents files. Licensee will send a statement stating that licensee has review regulations in regards to resident files.

Type A

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not ensure 3 residents bedrooms had window screens. Two window screen in the kitchen was missing; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee will purchased 5 new window screens. Three window screens will be installed for the three residents bedrooms and two window screens will be install for the kitchen windows. Licensee will send POC pictures to LPA Lee by 05/12/2023 by 5:00 PM of bussiness hours.

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-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/05/2023 12:27 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: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(6)

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 licnesee shall maintain documentation pertaining to staff training in the personnel records..... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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 immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee will make sure S1 and S2 register for caregiver trainings and have their annual trainings completed. Licensee will ensure that staff trainings stays current. Licensee will review care staff training regulatons and send LPA documents of completed trainings and a statement of the review regulations. Licensee will send LPA copies of completed trainings and statement to LPA by POC date 05/12/2023 by 5:00 PM.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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