342701091-4-18-2024-27-AS-PLEE-D4FUMD-20240418154210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701091
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:42:28 PM

Document Has Been Signed on 04/18/2024 03:42 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 II		FACILITY NUMBER:	342701091
ADMINISTRATOR:	UNA WAQALALA		FACILITY TYPE:	740
ADDRESS:	5490 ENRICO BLVD		TELEPHONE:	(916) 578-8834
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	15	CENSUS:	DATE:	04/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Veniana Banuve		TIME COMPLETED:	03:55 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	On 04/18/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee and Support staff (SS) Perla Mancillas arrived at the facility to conduct an unannounced annual inspection. LPA and SS met with direct care staff, Veniana Banuve and explained the purpose of the visit. Direct care staff called administrator, Una Wagalala. LPA and SS was informed that administrator is not able to join the visit and that direct care staff Veniana will assist with today’s visit. Administrator certificate # is 6056441740 and will expire on 07/08/2024. The current census is 13 with 3 facility staff. This facility is a single story building licensed to serve fifth teen (15) non-ambulatory residents and approved for 1 hospice residents. LPA and SS inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPA and SS observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA and SS observed residents’ room 101 was occupied by two facility staff which does not reflect the facility sketch and fire clearance. LPA and SS observed a folded roll out bed in residents’ room 102. It was learned that a staff sleeps on the roll out bed either in the activity room or the living room. It was also observed that the resident bathroom inside bedroom 102 is locked during the day and open for resident’s use at night due to the toilet leaking. LPA Lee did not observed any leak in the bathroom during today's visit. LPA and SS toured the kitchen and observed the pantry locked and not accessible to residents at this time. The facility had sufficient seven day non-perishable food supplies. It was observed that two day perishable food supplies were not sufficient for 13 residents in care. Hot water temperature was measured at 130.1 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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 04/18/2024 03:42 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 SOUTH ASC, 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. Hot water temperature was measured at 130.1 degrees Fahrenheit in resident bathroom sink, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to adjust the water heater immediately and ensure that the water is within regulation. Administrator will conduct a water temperature check that will include a water log for the rest of the month. The water log will be emailed to LPA Lee by POC date 04/26/24 by end of day 5:00 PM.

Type A

Section Cited

CCR

87307(a)(2)(B)

Personal Accommodations and Services

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. It was learned that a staff sleeps on the roll out bed either in the activity room or the living room. The facility did not follow the facility sketch and fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to picked up roll out bed immediately. Administrator will ensure that there are no facility staff sleeping in any room that is not licensed for facility. Administrator will read the regulation cited and provide a written statement acknowledging understanding of the regulation by POC date 04/19/2024 by end of day 5:00 PM.

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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE ELDERLY CARE II	FACILITY NUMBER: 342701091
	VISIT DATE: 04/18/2024

NARRATIVE

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Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 04/03/2024. LPA and SS observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA and SS observed toxins located in the hallway closet and kept locked and inaccessible to residents. LPA and SS observed sharp knives kept locked and inaccessible to residents. LPA and SS checked medication storage and found medication to be locked away and inaccessible to residents. LPA and SS reviewed and compared 4 medication administration record (MAR) along with residents’ medications. Records reviewed indicated that 1 out of 4 MAR log was inaccurate. Three out of 9 medication instruction did not have the current instruction information. The first aid kit was checked, and it was missing the thermometer. LPA Lee requested resident and staff files for review. LPA Lee reviewed 6 out of 13 resident files and 3 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and 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.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 04/26/2024 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility staff Veniana Banuve.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/18/2024 03:42 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 SOUTH ASC, 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

87555(b)(26) General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and facility inspection, the Licensee did not ensure that there were sufficient 2 days perishable food. This posed a immediate health and safety risk to residents in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator stated that there is a food delivery scheduled for today. Administrator agrees to have sufficient 2 days perishable on the premises at time. Administrator will send LPA receipt of groceries purchase to by 04/19/2024 end of day 5:00 PM. Administrator will read the regulation cited and provide a written statement acknowledging understanding of the regulation. POC will be provided to LPA Lee by 04/26/2024 by end of day 5:00 PM.

Type A

Section Cited

CCR

87307(a)

87307(a) Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and facility inspection LPA and SS observed residents’ room 101 was occupy by two facility staff which does not reflect the facility sketch and fire clearance. This posed a immediately health and safety risk to residents in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to not have any live in staff and will have 24/7 care and supervision to resident at all times. Facility staff will remove all personal items in resident bedroom 101. Administrator will read the regulation cited and provide a written statement acknowledging understanding of the regulation by POC date 04/26/2024.

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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/18/2024 03:42 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 SOUTH ASC, 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.269

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. LPA and SS observed the facility pantry locked and was not accessible to resident in care, which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Facility staff unlock refrigerator during today’s visit. Administrator agrees to ensure that the pantry is unlock at all times. Administrator will read the regulation cited and provide a written statement acknowledging understanding of the regulation. POC will be provided to LPA Lee by 04/26/2024 by end of day 5:00 PM.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/18/2024 03:42 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 SOUTH ASC, 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (b) (2) To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview resident bedroom 102 bathroom were observed locked. It was learned the bathroom is locked during the day and unlocked at night, this poses an potential health, safety or personal rights to resident in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Facility staff unlocked resident bathroom immediately. Administrator agrees to ensure that resident bathroom is unlocked at all times. Administrator will read the regulation cited and provide a written statement acknowledging understanding of the regulation. POC will be provided to LPA Lee by 04/26/2024 by end of day 5:00 PM.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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