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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701174
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:10:11 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
07/16/2024 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240716083150
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: 4DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Ilaisa NiutabuaTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff handled resident in a rough manner while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to deliver complaint investigation findings. LPA Valerio met with facility staff Ilaisa Niutabua, and explained the purpose of the visit.

The investigation consisted of interviews with staff, interviews with residents, and facility record review. The following has been determined as it relates to the aforementioned allegations.

According to a report provided to the Regional Office, it was alleged that Resident 1 (R1) was pushed two (2) times by a staff member and had their cathetar ripped from their body. LPA attempted to contact the reporting party three times; however, was unsucessful.

LPA Valerio interviewed staff. Staff 1 (S1) reported S1 has not seen any staff hit, push, or yell at residents.S1 reported having a good relationship with all the residents.
Continues on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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-20240716083150
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: 10/30/2024
NARRATIVE
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Continues from LIC 9099

S1 stated R1's catheter was leaking and had to be sent to the hospital. S1 stated staff do not touch the catheter and only nursing staff does it. According to an interview with Staff 2 (S2), S2 remember R1. R1 was observed by S2 cutting R1's own catheter bag. S2 reported R1 would find random items to cut the bag. R1 would do this multiple times and be sent to the hospital each time. S2 reported the last time R1 was sent to the hospital, R1 never came back. According to an interview with Staff 3 (S3), S3 does not remember R1.

LPA Valerio interviewed residents. LPA Valerio was unable to find information for R1 to conduct an interview. LPA Valerio interviewed Resident 2 (R2). R2 reported staff being great and had nothing to complain about here. R2 has not observed staff handling residents in a rough manner. According to an interview with Resident 3 (R3), R3 feels their needs are being met at the facility. R3 reported staff being gentle and kind.

According to Administrator Unaisi, R1 went to the hospital and never returned to the care facility. The administrator reported she was unaware of where R1 moved and was not informed by the placement agency.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held with facility staff, and a copy of report was left at the facility with staff Ilaisa Niutabua.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2