342701091-3-24-2023-27-AS-VMOI-CQ8UZR-20230324160157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701091
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:02:08 PM

Document Has Been Signed on 03/24/2023 04:02 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ABOUNDING PEACE ELDERLY CARE II		FACILITY NUMBER:	342701091
ADMINISTRATOR:	WAGALALA, UNA		FACILITY TYPE:	740
ADDRESS:	5490 ENRICO BLVD		TELEPHONE:	(916) 578-8834
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	15	CENSUS: 13	DATE:	03/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Una Wagalala		TIME COMPLETED:	04:15 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 Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced at the facility on Friday, March 24, 2023 to conduct an annual inspection. LPAs Moleski spoke with administrator Una Waqalala over the phone and explained the purpose of the visit. Waqalala arrived later during the visit. When LPAs Moleski and Lund arrived at the facility, they observed a bicycle lock wrapped around the front gate, making it inaccessible to residents in the event of a fire. LPAs Moleski and Lund toured the facility with staff. LPAs Moleski and Lund observed the common areas, resident bedrooms, restrooms, kitchen, dining areas, and outdoor areas. Fixtures and furnishings in all areas were sufficient to meet the needs of the residents. The facility's refrigerator and food storage areas contained the required two-day perishable supply and seven-day nonperishable supply. Water temperature was measured and was within the required range of 105 degrees to 120 degrees. The temperature of the facility was within the required range of 68 and 85 degrees. LPAs Moleski and Lund observed the facility's locked medication storage cabinet. Medication was locked and inaccessible to residents. LPAs Moleski and Lund observed a cabinet for storage of cleaning supplies. The facility's first aid kits were observed to contain all the required components. LPAs Moleski and Lund reviewed three resident files for R1, R2, and R3, and two staff files for S1 and S2. LPAs Moleski and Lund requested an updated LIC 500. [Continued on 809-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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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Document Has Been Signed on 03/24/2023 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(I)

This requirement is not met as evidenced by: LPA observation of a bicycle lock locking front gate.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Staff will remove bicycle lock from front gate.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE II	FACILITY NUMBER: 342701091
	VISIT DATE: 03/24/2023

NARRATIVE

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Two residents, R4 and R5, were interviewed. One staff member, S3, was interviewed.

Based on LPAs Moleski and Lund's observation of a bicycle lock preventing egress through the front gate, a citation is being issued per 22 CCR 87705(I). Technical assistance advisory notes were generated to address live-in staff and license capacity.

LPAs Moleski and Lund conducted an exit interview with Waqalala and a copy of this report and appeal rights were left with her.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

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