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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:28:41 PM


Document Has Been Signed on 06/07/2022 02:28 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
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:
06/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Facility Staff, Tavaita SeruvatuTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on June 7, 2022 at 01:30 p.m. conducted a health and safety check. LPA met with facility staff Tavaita Seruvatu and explained the purpose of today's visit.

LPA observed two caregivers present at the facility.LPA confirmed both caregivers are background cleared and not excluded from working at the facility. LPA evaluated the physical plant to ensure the health and safety of the residents in care. LPA inspected the facility including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room, and backyard area. LPA observed that rooms inspected are equipped with the required furniture and there is sufficient lighting throughout the facility. LPA observed running water in the bathrooms and kitchen sink areas. LPA observed a facility caregiver accompanying a resident to an appointment. LPA observed caregivers cleaning up the lunch meal that included egg salad, and sunny delight juice. LPA observed caregivers ordering Kentucky Fried Chicken for residents dinner meal.

LPA observed sufficient seven-day non-perishable and two-day perishable food supplies.
Health and Safety check today included the overall safety of the facility including food supply, physical plant and staffing.

No deficiencies were cited today pursuant to Title 22 rules and regulations.

Exit interview conducted with facility staff Tavaita Seruvatu and a copy of report left at facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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