342701174-7-28-2022-27-AS-CACL-CHBRZB-20220815132739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701174
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:48:10 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220624103311

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: 5	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Unaisi Waqalala		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Residents engaged in physical altercations while in care.
Staff allowed residents to engage in physical altercations.

INVESTIGATION FINDINGS:

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On 7/28/22, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on statements obtained, it was learned that there was no physical altercation between residents. Residents and staff who were interviewed stated no fight has occurred in the facility. It was learned that on 6/12/22, resident (R3) came out of his room and began throwing and breakings things throughout the facilty. R3 also tried to attack resident (R4); however, staff was able to redirect R3 on time and tries to calm R3 down. 9-1-1 and EMT was called, and R3 was taken to the hospital for evaluation. It was learned that no one was hurt during this incident.

Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220624103311

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342701174
	VISIT DATE: 07/28/2022

NARRATIVE

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Based on information gathered, LPA finds the allegations above to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies were cited. An exit interview was conducted with Administrator Unaisi Waqalala, and a copy of the report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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