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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:21:02 AM


Document Has Been Signed on 07/07/2023 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:
07/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alicia ReidTIME COMPLETED:
11:35 AM
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On 7/7/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a quarterly health and safety visit following the Informal Conference conducted on 6/19/2023. Upon LPAs arrival, facility staff Alica Reid and Eliki Seruvatu were present at facility. LPA requested that Alicia go ahead and contact the facility designated Administrator, Unaisi Waqalala, to inform her that CCL was present at this time. LPA Truong was advised that staff Alicia can assist LPA with today’s inspection and sign the report.

LPA toured and inspected the physical plant inside and outside to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in sanitary condition. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water measured at 114.8 degrees Fahrenheit. The temperature inside was observed at 69 degrees Fahrenheit. Fire extinguisher and first aid kit was up to date.

LPA reviewed (2) staff files, including criminal record clearances. 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. LPA verified staff training for staff file reviews. Based on a review of this facility during today’s visit, it was determined that this facility was found to be in compliance at this time.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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