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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701091
Report Date: 11/22/2022
Date Signed: 11/22/2022 02:58:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220823173615
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: DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Unaisi WaqalalaTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Resident's eloped from facility.
INVESTIGATION FINDINGS:
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On 11/22/22 at 1:30 pm Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to deliver complaint findings. LPA met with Administrator Una Waqalala and explained the purpose of the visit.

Based on interviews and record reviews conducted it is determined that resident R1 and R2 had eloped from the facility on 8/10/2022 and 8/15/2022. Review of R1’s LIC 602 revealed that R1 has been determined to be unable to leave the facility unassisted by his physician. Residents were located by law enforcement and brought back to the facility.

Based on the findings noted above, LPA finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An immediate civil penalty of $500 is assessed.
Exit interview was conducted, a copy of the report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220823173615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
87705(k)(6)
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Care of Persons with Dementia. Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility.
This requirement is not met as evidence by:
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The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Licensee/Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL
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Based on reviewed records, the facility did not comply with section cited above. R1 AWOL'd from the facility and was found wandering in the community unsupervised by facility staff members. The LIC 602 states R1 was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.
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and a signature sheet of all staff who attended. The Adminnstrator shall email the date of the in-service training to LPA by 11/23/22 to meet the 24 hour POC requirement.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2