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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701091
Report Date: 11/30/2022
Date Signed: 11/30/2022 12:40:06 PM


Document Has Been Signed on 11/30/2022 12:40 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: 12DATE:
11/30/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Una WaqalalaTIME COMPLETED:
01:00 PM
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On 11/30/22 at 9:30 AM, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a post-licensing inspection. LPA met with Administrator Una Waqalala and explained the purpose of the visit. Administrator Certificate # 6056441740 expires 7/8/2024. There are currently 12 residents currently living at the facility.

LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature was measured at 118.9*F. 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.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. 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) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.

LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

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: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ABOUNDING PEACE ELDERLY CARE II
FACILITY NUMBER: 342701091
VISIT DATE: 11/30/2022
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LPA reviewed (3) resident files and (3) staff files, including criminal record clearances. LPA confirmed all residents’ files have required records. 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.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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