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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701091
Report Date: 02/12/2026
Date Signed: 02/12/2026 02:20:11 PM

Document Has Been Signed on 02/12/2026 02:20 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ABOUNDING PEACE ELDERLY CARE IIFACILITY NUMBER:
342701091
ADMINISTRATOR/
DIRECTOR:		UNA WAQALALAFACILITY TYPE:
740
ADDRESS:5490 ENRICO BLVDTELEPHONE:
(916) 898-1793
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 15CENSUS: 14DATE:
02/12/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Una WaqalalaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 2/12/26 at 9:30am, Licensing Program Analyst (LPA) Kevin Gould conducted a case management deficiencies inspection to address deficiencies of facility operation while conducting an unannounced case management inspection. LPA met with Administrator Una Waqalala.

LPA observed the following: Expired canned goods and perishable food supplies such as milk and items that are required to be refrigerated after opening were stored in cabinet such as jelly and BBQ sauce.

LPA also observed medications stored in one of the refrigerators that were unsecured from residents and stored with resident's food supply. LPA observed one resident's medication was mixed with hot chocolate and was unaware medications were being administered. LPA observed no physician's order and this was confirmed by the administrator and staff member (S1) who hid medications in hot chocolate. In discussions with S1 it was determined they did receive training in medications but did not take any exam to verify competency of medication administration per regulations.

Additionally, LPA observed one staff member (S2) not associated to the facility. LPA confirmed the individual has a criminal record clearance but was to associated to the facility.

Per the California Code of Regulations, Title 22, The following deficiencies are cited. An immediate civil penalty was also issued.

Exit interview conducted and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Kevin Gould
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/12/2026 02:20 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/12/2026 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE II
FACILITY NUMBER: 342701091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2026
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by LPA review of staff files and individual associations and observed R1 (see LIC 811 dated
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Administrator agrees to associate R1 by the POC due date.
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2/12/26) did not have their criminal record clearance associated to the facility which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
02/13/2026
Section Cited
CCR87465(a)(5)(D)

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Incidental Medical and Dental Care: Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
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All staff who provide medication administration to residents must receive updated training on medication administration and must pass an examination per the health and safety code demonstrating competency.
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This requirement was not met as evidenced by LPA observations of staff members camouflaging medications in other substances as LPA observed open capsules of medications next to a cup of hot chocolate and residue of medications still visible in the cup. This was confirmed by S1 who administered the medications which poses an immediate health safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2026 02:20 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/12/2026 at 11:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE II
FACILITY NUMBER: 342701091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2026
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by LPA observations
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Administrator has ordered a lock box and will place medications in lock box immediately upon arrival.
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 of a resident medication stored in a fridge without a lock box and accessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
02/13/2026
Section Cited
HSC1569.69(a)(5)

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Employees assisting residents with self-administration of medication; training requirements: To complete the training requirements set forth in this subdivision, each employee shall pass an examination that tests the employee's comprehension of, and competency in, the subjects listed in paragraph (3). This requirement was
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All staff who provide medication administration to residents must receive updated training on medication administration and must pass an examination per the health and safety code demonstrating competency.
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not met as evidenced by statements from S1 and file review for S1 that indicates S1 did not receive or pass a competency exam for medication administration which poses an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2026 02:20 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/12/2026 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE II
FACILITY NUMBER: 342701091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2026
Section Cited
CCR
87468.2(a)(6)

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Additional Personal Rights of Residents in Privately Operated Facilities: To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by LPA observations of staff member camouflaging medications in resident's hot chocolate without the
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Administrator has agree to review all personal rights for residents with all staff members and provide the department staff signatures indicating they have all reviewed resident personal rights.
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resident's knowledge which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
02/13/2026
Section Cited
CCR87405(d)(2)

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Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by the number of violations observed and the nature of the violations has demonstrated to the department the
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Administer has agreed to provide a statement that if offerred they would participate in TSP.
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 administrator has not demonstrated an knowledge of or ability to conform to the applicable laws, rules and regulations which poses an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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