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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 06/12/2023
Date Signed: 06/13/2023 09:53:14 PM


Document Has Been Signed on 06/13/2023 09:53 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/13/2023 07:06 AM

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

NARRATIVE
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On 06/12/2023, Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a case management visit. LPA met with Unaisi Waqlala and explained the purpose of the visit.
The purpose of the visit today, is in response to opening a complaint investigation number #
27-AS-20230609170234.

It was learned that two (2) out of two (2) staff are background cleared, but not associated to the this facility prior to working at this facility. During the facility visit, the Department, asked the Licensee to seek replacement caregivers immediately. It was also learned that the sliding door to go out to the courtyard is not in good repair. LPA Lee observed a care staff having a hard time opening and closing the sliding door.

Licensee stated she will associate all employees by sending criminal record clearance transfer to SACASCTransferRequest@dss.ca.gov


The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and
California Health and Safety Code and documented on LIC 809-D. Immediate Civil Penalty were assessed.

An exit interview was conducted, and a copy of this LIC 809, LIC 809-D report and appeal rights were given to the Licensee/Administrator Unaisi Waqlala

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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 06/12/2023 12:47 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 III ELDERLY CARE
FACILITY NUMBER: 342701174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2023
Section Cited
CCR
87411(g)(2)

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87411(g)(2)Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Sectio(c)...
This requirement was not met as evidenced by:

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Licensee stated they will associate all employees by sending criminal record clearance transfer to SACASCTransferRequest@dss.ca.gov by POC date 06/12/2023 by 5:00 PM
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Based on observations and record review, the licensee did not ensure 2 out of 2 staff located on the premises during the time of visit were associated to the facility roster.
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Type B
06/19/2023
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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The Licensee agrees to repair or replace the sliding glass door submit picture of completed work to LPA by POC due date 06/19/2023 by 5:00 PM
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Based on observation, the licensee did not ensure the sliding door out to the courtyard is in good repair. LPA Lee observed a care staff having a difficult time opening and closing the sliding door.
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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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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