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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701091
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:15:42 PM


Document Has Been Signed on 03/09/2022 04:15 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ABOUNDING PEACE ELDERLY CARE IIFACILITY NUMBER:
342701091
ADMINISTRATOR:WAGALALA, UNAFACILITY TYPE:
740
ADDRESS:5490 ENRICO BLVDTELEPHONE:
(916) 578-8834
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:15CENSUS: 0DATE:
03/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Una Wagalala, ApplicantTIME COMPLETED:
04:30 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) Tung Truong arrived at this facility announced on 03/09/2022 at 1:25 PM to conduct a pre-licensing inspection. LPA met with Una Wagalala, Applicant and explained the purpose of the visit.

The facility will be licensed for a capacity of 15 non-ambulatory residents. Una Wagalala holds current administrator certificate # 6021870740 which will expire on 07/08/2022.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The facility has eight bedrooms. LPA observed rooms to have required furniture. LPA observed there were no residents in care at this time.

LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 117.5*F during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 72*F which was within the required range of 68-85*F.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility were in good repair. LPA observed the area where the staff and resident files were locked and readily available for review. LPA also conducted the inspection tool.

Report Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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 2


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 II
FACILITY NUMBER: 342701091
VISIT DATE: 03/09/2022
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
26
27
28
29
30
31
32
The facility had Covid-19 posting throughout the facility. The facility had a mitigation plan completed and provided it to Licensing for approval on 2/2/22. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. LPA discovered that Applicant Una Wagalala has completed Component III before and will therefore waive this requirement.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2