<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:44:20 PM


Document Has Been Signed on 06/29/2023 12:44 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: 6DATE:
06/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alicia ReidTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 06/09/2023 at 11:34 AM to conduct an unannounced Plan of Correction (POC) visit. LPA met with Alicia Reid. LPA explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that were due 06/26/2023. During today's visit, LPA Lee toured and inspected the facility to ensure deficiency previously cited on 06/12/2023 have been corrected.

LPA reviewed staff criminal record clearances and 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.

Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 87411(g)(2) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

2. Deficiency cited under Title 22 Regulation 87303(a) has been cleared. Licensee complied with the terms of the POC by POC due date.

Proof of correction was submitted by email on 06/26/2023. Licensee complied with the terms of the POC by POC due date. Facility was provided with POC cleared letter.
Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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 1