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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701174
Report Date: 07/22/2026
Date Signed: 07/22/2026 03:01:25 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
02/11/2026 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20260211103325
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:
07/22/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Esther Tabua, Assistant AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On July 22, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow-up investigation visit. LPA initially met with staff on duty, Patrice Patterson (S1) and stated the purpose of the visit. The assistant administrator, Esther Tabua (S2) was notified and arrived later during the visit.
Present upon arrival were six residents with one staff on duty.

Allegation - The facility allowed excluded individuals to work in the facility:
The investigation into this allegation consisted of interviews, record reviews and observations.
On February 19, 2026, interviews were completed with 5 of the 5 residents. Of the five residents who were interviewed, two could not say if they had seen the excluded individuals, E1 or E2, at the facility after being shown their photos. One of the resident stated they had seen E2 but could not remember the exact or approximate date.
Staff interviews revealed that when shown photos of E1 and E2, staff stated they knew both individuals. At least two staff members stated they had not seen either of them at the facility since starting employment.
{1 of 2}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
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 5
Control Number 27-AS-20260211103325
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: 07/22/2026
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
26
27
28
29
30
31
32
At least one staff member stated that they had not seen E1 at the facility since employment but stated they saw E2 at the property about one month earlier or at least one time since starting work. This staff stated when E2 was here E2 remained outside with a maintenance person and did not enter the facility and that only the maintenance person went inside; they could not confirm whether E2 had any contact with residents.
Additional interviews was conducted on July 22, 2026 where one resident who stated who also confirmed, after being shown photos of E1 and E2, R6 stated they did not recognize either individual and had not seen them at this facility since admission.
A review of the facility's LIC 500 Personnel Report found that E1 and E2 were not listed as employees. During facility visits on February 19, 2026, June 10, 2026, and July 22, 2026, no excluded individuals were observed at the facility and there were no reports that E1 or E2 were working there.
Based on interviews, record review, and observations, there was not enough evidence to show that the facility allowed excluded individuals to work in the facility. Therefore, the allegation is unsubstantiated.
****************************************************************************
Allegation - Staff are forging resident documents:

The investigation into this allegation consisted of interviews and record reviews.

On July 22, 2026, LPA Villanueva contacted the medical offices listed on the residents' Medical Assessments (LIC 602A) to verify whether the residents had been seen by their physicians. Some residents receive medical care through Kaiser and Dignity Health. The representatives stated they could not release or verify patient information because of their privacy policies. At least one resident receives care through a clinic which confirmed the resident's medical assessment information to be accurate. Two other residents receive care through another clinic and they were able to verify these residents in their care.

Interviews with staff members on February 19, 2026 and July 22, 2026, they stated they were not aware of any staff or the administrator forging resident documents or asking them to alter or change resident records.

Based on the information gathered during the investigation, there was not enough evidence to show that staff were forging resident documents. Therefore, the allegation is unsubstantiated.

A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.


Exit interview was conducted with Esther Tabua and a copy of this report and appeal rights were provided.
{2 of 2}
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/11/2026 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20260211103325

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:
07/22/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Esther Tabua, Assistant AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
The Administrator is not present at the facility for a sufficient amount of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On July 22, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow-up investigation visit. LPA initially met with staff on duty, Patrice Patterson (S1) and stated the purpose of the visit. The assistant administrator, Esther Tabua (S2) was notified and arrived later during the visit.
Present upon arrival were six residents with one staff on duty.

Allegation - The Administrator is not present at the facility for a sufficient amount of time:
The investigation into this allegation consisted of interviews, record reviews and observations.

{1 of 2}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260211103325
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: 07/22/2026
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
26
27
28
29
30
31
32
A review of Licensing Program Analyst (LPA) visits on February 19, 2026, June 10, 2026, and July 22, 2026, showed that the administrator was not present during any of the three visits. A review of the facility's Personnel Report (LIC 500), dated June 15, 2026, showed the administrator was scheduled to work at the facility on Mondays and Thursdays from 9:00 a.m. to 7:00 p.m.
During interviews, staff gave different statements about how often the administrator is at the facility. One staff member stated the administrator comes to the facility about one time per week and stays about five to six hours each visit. Another staff member stated the administrator comes about two times per week but could not remember the last time they saw the administrator at the facility but stated the administrator usually stays four to five hours each visit. Another staff stated the administrator comes to the facility two to three times per week and stays about eight hours each visit. These statements were not consistent with each other and did not match the administrator's work schedule listed on the LIC 500.
Resident were also interviewed about the administrator's presence at the facility. At least 4 of 6 residents stated they do not know who the administrator, Una, was when asked and are unable to confirm if administrator Una is present at this facility at a sufficient amount of time.
Based on the administrator not being present during multiple LPA visits, the conflicting staff statements about how often the administrator is at the facility, and residents being unable to identify or recall seeing the administrator, the evidence supports that the administrator was not present at the facility for a sufficient amount of time. Therefore, the allegation is substantiated.
A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Plan of correction and appeals were discussed during the exit interview with Esther Tabua; and a copy of this report and appeal rights were provided to facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211103325
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2026
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
The administrator…shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Per discussion, the administrator will start documenting their presence at the facility including the date, arrival time, departure time, and duties completed during each visit; will title it Administrator Visit Log.
8
9
10
11
12
13
14
Based on interviews, record reviews and observations, the administrator were not present during multiple LPA visits, the conflicting staff statements about how often the administrator is at the facility, and residents being unable to identify or recall seeing the administrator. This poses a potential health, safety, or personal rights risks to residents in care.
8
9
10
11
12
13
14
Administrator Visit Log from 7/22/26 to 7/29/26 will be submitted to the Department by POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5