342701174-5-4-2023-27-AS-TTRG-CRHVQR-20230504163847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 05/04/2023
Date Signed: 05/04/2023 04:38:52 PM

Document Has Been Signed on 05/04/2023 04:38 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Unaisi Waqalala		TIME COMPLETED:	04:50 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	On 5/4/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Upon LPAs arrival, facility staff Kohata Qalo was present and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator holds current certification #6056441740 and expires on 7/8/2024. The facility is licensed for 6 non-ambulatory residents, of which 1 may be bedridden in bedroom #5 only. Approved hospice waiver for 1. There are 6 residents in care at this time. LPA inspected the physical plant including but not limited to the common area, kitchen, pantry, dining area, resident bedrooms, resident bathrooms, laundry area and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 111.7 degrees Fahrenheit. Facility thermostat observed at 73 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication cabinet and found medication to be locked away and inaccessible to residents. Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ABOUNDING PEACE III ELDERLY CARE	FACILITY NUMBER: 342701174
	VISIT DATE: 05/04/2023

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LPA requested resident and staff files for review. LPA reviewed (3) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following forms and documents were requested to be submitted within 15 days:
LIC308 Designation of Administrative Responsibility, LIC 500 Personnel Report, LIC610 Emergency Disaster Plan and Proof of Current Liability Insurance.

No deficiencies were observed during today’s visit pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview held with Administrator. A copy of the report was given at the conclusion of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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