342701091-10-10-2023-27-AS-KHOS-CWJKGG-20231012075330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701091
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:59:42 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
08/16/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230816114138

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:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Veniana Banuve		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility allowed excluded person to facilitate operations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with staff member Veniana Banuve. LPA Moleski spoke with facility administrator Una Waqalala over the phone and explained the purpose of the visit.

This investigation consisted of record review and interviews with staff members, residents, residents’ responsible parties, an excluded individual (E1), and an Alta California Regional Center (ACRC) representative.

During interviews, both facility administrator Una Waqalala and E1 said E1 is a placement agent.

LPA Moleski interviewed three staff members (S1-S3). S1 and S3 said E1 often calls the facility to ask about residents. S1 said E1 is a staff member of the facility and manages the payroll for facility staff.
[continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230816114138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/10/2023

NARRATIVE

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S1 said that E1 was present at the facility for one day to clean out a resident’s room while they were in the process of moving out. S1 said the resident moved out in mid-September 2022. S3 described E1 as a staff member.

LPA Moleski reviewed an email sent by E1 on August 17, 2023 asking staff to deliver a billing agreement to a former resident.

LPA Moleski interviewed seven residents’ responsible parties. Of these, responsible parties for R4, R6, R9, R10, R11, and R13 said they had been in contact with E1.

The department has determined the following as it relates to the allegation that the facility allowed an excluded person to facilitate operations:

Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87355(e)(1). An immediate civil penalty in the amount of $100 per day for one day, for a total of $100, was assessed. An exit interview was held and a copy of this report and appeal rights were left with Banuve.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230816114138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/11/2023 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	Criminal Record Clearance: "(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department..." This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review a stipulation order regarding E1. LPA Moleski will email this stipulation order to Una Waqalala by EOD on 10/10/23. Waqalala agrees to write a statement of acknowledgement, stating that she has reviewed this stipulation. Waqalala agrees to email LPA Moleski a copy of this written statement. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on interviews and record review, E1 facilitated operations without a criminal record clearance, which poses an immediate health and safety risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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