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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:21:06 AM


Document Has Been Signed on 05/19/2022 11:21 AM - 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 III ELDERLY CAREFACILITY NUMBER:
342701174
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:10339 SAGRES WAYTELEPHONE:
(916) 667-8465
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
05/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Unaisi Waqalala, Applicant TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility announced on 05/19/2022 at 9:35 AM to conduct a Pre-licensing inspection. LPA Truong was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Upon LPAs arrival, Caregiver Tavaita Servatu was present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Unaisi Waqalala, Applicant and stated the purpose of today’s visit. The facility will be licensed for a capacity of 6 non-ambulatory residents.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed there were six residents in care at this time.

LPA observed the temperature inside the facility was measured at 75*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 110.5*F. LPA observed 2-day perishables and 7-day non-perishables. LPA observed the centrally stored medications area, cleaning supplies, and staff files to be locked. Resident rooms were sanitary and had the required furniture and furnishings. Resident bathrooms observed to have non-skid mats, soap, paper towels, and closed lid garbage cans. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers and first aid kit were up to date. LPA observed no obstruction of emergency exits inside or outside of facility.

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: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 III ELDERLY CARE
FACILITY NUMBER: 342701174
VISIT DATE: 05/19/2022
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The facility had Covid-19 posting throughout the facility. The facility had a mitigation plan completed and provided it to Licensing for approval on 3/16/22. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. LPA discovered that Applicant Unaisi Waqalala has completed Component III before and will therefore waive this requirement. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2