342701174-4-22-2024-27-AS-CVAO-D4KUJK-20240422153741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:37:49 PM

Document Has Been Signed on 04/22/2024 03:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ABOUNDING PEACE III ELDERLY CARE		FACILITY NUMBER:	342701174
ADMINISTRATOR:	WAQALALA, UNAISI		FACILITY TYPE:	740
ADDRESS:	10339 SAGRES WAY		TELEPHONE:	(916) 667-8465
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	04/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Eliki Seruvatu		TIME COMPLETED:	03:50 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) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with facility staff Eliki Seruvatu, and explained the purpose of the visit. Administrator Unaisi Waqalala was contacted via cell phone by the facility staff. LPA observed one (1) staff and six (6) residents in care. Staff was observed preparing lunch for the residents in care. Today, lunch was pepperoni pizza and salad along with a choice of beverage. Three residents were observed watching television while eating lunch, one in their room watching television, another resident having a family and Chaplin visit, and another resident eating lunch with their family. LPA Valerio and staff E. Seruvatu toured the facility to ensure compliance with Title 22 regulations. LPA observed the front living room space to be clean, furnished, and free from debris. LPA observed five (5) resident bedrooms. Resident bedrooms were clean, furnished, and free from debris or odors. LPA observed one (1) staff bedroom, which was located inside the house. Resident bathrooms were observed to be stocked with paper towels, toilet paper, skid mats, hand rails, soap, hand sanitizer, and a trash can. Hot water was measured at 105.0*F degrees. Technical assistance (TA) was provided for the sink located in the "staff" bathroom. The sink faucet handle was observed to be loose and will need to be repaired. According to staff, residents have access to use the bathroom. The common area and kitchen area was observed to be clean and free from debris. The facility had a food supply to meet the minimum requirements of two (2) days of perishable food items and seven (7) days of non-perishable food items. The kitchen stove was observed to have a missing door handle with a screw sticking out of the door. A picture was obtained for reference. According to staff, staff utilize the smaller conventional oven for every items and only use the large oven as needed. LPA observed sharps, chemicals, and medications to be locked and inaccessible to residents in care. Continues on LIC 809 - C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE III ELDERLY CARE	FACILITY NUMBER: 342701174
	VISIT DATE: 04/22/2024

NARRATIVE

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Continued from LIC 809

LPA observed the garage area. LPA observed the garage to have furniture, a bed with a pillow, a couch, and other storage items. According to staff, the bed is not used for sleeping and utilized as a break area. LPA reviewed the facility sketch submitted during the pre-licensing inspection. The facility sketch submitted along withe the facility sketch posted at the facility does not indicate the garage to be a staff area. A picture was obtained for reference.

The facility's last fire drill was conducted November of 2023. LPA observed the fire detector and carbon monoxide detector to be in working condition. The facility fire extinguisher located in the kitchen was observed to be expired as evidenced by the arrow pointing in the red area and a previous annual maintenance of April 04, 2023. Due to this violation, facility staff was informed that the licensee will be cited and an immediate civil penalty will be assessed today in the amount of $500.00. A signature was obtained on the LIC 421IM.

LPA reviewed four (4) staff files. 2 out of 4 staff files reviewed were observed to be missing annual training documentation. 4 out of 4 staff files were observed to have a current first aid certificate.

LPA reviewed three (3) resident files. 1 out of the 3 resident files reviewed were observed to be incomplete. One resident file was missing their annual Appraisal & Needs and Service Plan.

LPA requested the following annual documentation be sent to the Regional Office by 04/29/2024: An updated LIC 500, updated LIC 308, updated LIC 309, updated LIC 610, and a copy of current liability insurance.

Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 809 - D page. Appeal rights were provided. An exit interview was held, and a copy of the report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2024 03:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE III ELDERLY CARE	FACILITY NUMBER: 342701174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers were observed to be out of compliance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/23/2024
	Plan of Correction
1 2 3 4	Licensee to obtain a fire extinguisher that is fully charged by POC due date. Licensee to send notfication and proof that a fire extinguisher was obtained.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 04/22/2024 03:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE III ELDERLY CARE	FACILITY NUMBER: 342701174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited by having the kitchen oven appliance to be in need of repair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Licensee to repair the oven door or buy a new oven by POC due date. Licensee to send LPA notification and proof once it has been completed.

Type B

Section Cited

CCR

87411(c)

87411Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 2 out of 4 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Licensee to send LPA Valerio copies of annual in-service training for staff by POC due date.

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/22/2024 03:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABOUNDING PEACE III ELDERLY CARE	FACILITY NUMBER: 342701174
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

87463 Reappraisal (c)The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 1 out of 3 resident files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Licensee to send LPA a copy of the completed Appraisal - Needs & Service Plan by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5