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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701174
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:58:54 PM

Unsubstantiated


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
08/01/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220801121335
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:
09/21/2022
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Unaisi Waqalala TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff member hit resident while in care.
Facility staff member engages in physical altercations with resident while in care.
Facility staff threaten resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 9/21/22 at 3:25 pm to deliver findings for this complaint. 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 deemed that there is insufficient evidence to substantiate the allegations noted above. Residents in care stated that they were unaware of any physical altercations between staff and R1. Moreover, residents stated they did not observe staff threaten residents.

Report continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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-20220801121335
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: 09/21/2022
NARRATIVE
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As a result of this investigation, LPA finds the allegations above 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 conducted with Administrator Unaisi Waqalala and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2