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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 06/19/2023
Date Signed: 06/24/2023 04:51:13 PM


Document Has Been Signed on 06/24/2023 04:51 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 AC/SC, 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: DATE:
06/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Unaisi WaqalalaTIME COMPLETED:
10:00 AM
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A virtual Informal conference was conducted today on 06/19/2023 at 9:00 AM via Microsoft Teams. The purpose of the meeting is to discuss complaint allegations and non-compliance concerns. Present in the meeting are Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Pang Lee, Licensee Unaisi Waqalala. The informal conference process was explained during this meeting to include the administrative process.

Discussed Concerns:
The following concerns were discussed: Recent allegation, staff fingerprint clearances, staff associations, staff elopement, staff files, mandated reporting and Technical Support Program (TSP).

The facility has stated they will do the following to achieve continued and substantial compliance:
· Ensure hired staffs are fingerprint cleared and trained before staff starts working at the facility.
· Ensure all staff are compliant with all required training's.
· Conduct training for all staff and ensure all staff knows where staff and residents file are kept in the facility.
· Ensure all staff and resident files are current and complete.
· Ensure and train all staff to be comfortable and not get nervous when CCL visits
· Ensure two current staff completes their administrator training and are associated to all facilities
· Ensure all staffs are associated to facility Abounding Peace Elderly Care 342700827, Abounding Peace Elderly Care II 342701091 and Abounding Peace III Elderly Care 342701174 staff not associated to other facilities when coverage is needed.

Continued LIC-809

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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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
VISIT DATE: 06/19/2023
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· Licensee agrees to dedicate self to Abounding Peace III Elderly Care 342701174 once she has current and qualified administrator for both Abounding Peace Elderly Care 342700827 and Abounding Peace Elderly Care II 342701091 and then licensee will hire a qualified administrator for Abounding Peace III Elderly Care 342701174.
· Facility Administrator will ensure compliance plan is being followed at all times.
· Submit LIC 500 Personnel document and LIC 308 Designated Responsibility document to Community Care Licensing Department (CCLD) by June 26, 2023 by 5:00 PM.

Licensee Unaisi Waqalala reported all facility plans to achieve compliance will be submitted to the Community Care Licensing Department by June 26, 2023, by 5:00 PM.

Continued...

Community Care Licensing Department (CCLD) will do the following:


· Increase Monitoring
· Technical Support Program (TSP) referral

The licensee was advised failure to follow agreed plan could result in a Non-Compliance Conference.

No deficiencies were cited during today's meeting. An exit interview was conducted with facility representatives Unaisi Waqalal , and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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