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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701091
Report Date: 02/18/2022
Date Signed: 02/18/2022 04:27:56 PM


Document Has Been Signed on 02/18/2022 04:27 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
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:
02/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Una WagalalaTIME COMPLETED:
04:45 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
On 2-18-22 Licensing Program Analyst (LPA) Tirzah Hubbard conducted a pre-licensing visit. LPA met with Administrator and Licensee Una Wagalala and discussed the purpose of the visit.

LPA toured the physical plant of the facility.

LPA observed walls of the facility needing painting and borders of the facility replaced. LPA observed all trash cans in each room and around the facility with no lids. LPA observed 8 bedrooms that contained two beds each with furniture that consist of bed, dresser, night stand, chair, and grab bars. LPA observed pull fire alarms and tested out smoke detectors. LPA observed gate in kitchen area in disrepair. LPA observed 7 days of perishable and non-perishable foods in stock.

LPA observed all windows of the facility that contained window screens in disrepair.

LPA observed broken down vehicle in front of the facility that licensee has confirmed being placed there for two weeks. Licensee agreed to move vehicle by 2-21-22.

LPA observed an individual living in the home. Licensee stated, The individual will move out today on 2-19-22.

Licensee agreed all parts of the facility in disrepair will be fixed by 2-23-22 for approval.

Based on observation and tour of the physical plant. CCL will return at a later time to conduct a pre-licensing in order to approve license. LPA has reviewed CAB to discuss what needs to be replaced and fixed in the facility. The facility is not in compliance at this time.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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 1