342701174-5-18-2023-27-AS-KHOS-CSCHC2-20230531060401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701174
Report Date: 05/18/2023
Date Signed: 05/18/2023 11:17:13 AM

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
05/05/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20230505141817

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:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Unaisi Waqalala, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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On 5/18/2023, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to conclude the investigation of the above allegation and to deliver the 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. Regarding the allegation that staff did not treat resident with dignity and respect, it was determined that there was insufficient evidence to corroborate the allegation. Resident (R2) and (R3) who were interviewed reported that they did not hear staff yell or speak inappropriately to residents. Staff (S1) stated that he did not say anything to residents inappropriately.

Based on information obtained, LPA finds the allegation 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.

An exit interview was conducted, and a copy of this report was left at the facility.

Unsubstantiated

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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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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