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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701174
Report Date: 02/13/2024
Date Signed: 02/13/2024 05:15:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230609170234
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:
02/13/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Nepani TuivuTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff inappropriately touched resident
INVESTIGATION FINDINGS:
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On 2/13/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to deliver the findings for a complaint received on 6/9/23. LPA met with facility staff Nepani Tuivu and explain the purpose of the visit. LPA spoke with Administrator Unaisi Waqalala over the phone to discuss the conclusion for complaint and the findings. Administrator Unaisi Waqalala was unable to come to the facility and gave consent for staff to sign today's report.

Throughout the course of the investigation, the Department conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegation mentioned above. The investigation revealed that resident (R1) wasn't sure if staff (S1) was touching R1 for sexual arousal while cleaning R1. R1 reported that S1 never tried to force physically or inserted anything into R1. R1 stated that S1 stopped cleaning R1 when R1 asked S1 to stop. S1 denied touching R1 inappropriately and stated that S1 was only performing caregiver duties when cleaning R1.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20230609170234
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ABOUNDING PEACE III ELDERLY CARE
FACILITY NUMBER: 342701174
VISIT DATE: 02/13/2024
NARRATIVE
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This Department has investigated the allegation noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2