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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005215
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:26:43 PM


Document Has Been Signed on 08/01/2024 01:26 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ABUNDANT LOVE AND CARE FOR THE ELDERLYFACILITY NUMBER:
347005215
ADMINISTRATOR:BONITE, VIRGINIAFACILITY TYPE:
740
ADDRESS:2607 WALNUT AVENUETELEPHONE:
(916) 481-6817
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
08/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Nellie Morate and Virginia BoniteTIME COMPLETED:
01:40 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 8/1/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a deficiency LPA observed. LPA met with Caregiver and explained the purpose of the visit Caregiver then contacted Administrator via telephone.

Today's census is five residents in care with zero of hospice services, facility is licensed for six non-ambulatory hospice waiver of three.

During today's visit, LPA conducted a tour of R1's bedroom and observed the exterior door pathway to be obstructed with a mattress and a wheelchair. LPA took a photo of the following observation. When discussed with Administrator, she explained the items had been placed there for approximately two weeks now but it will be removed immediately.

LPA and Administrator additionally discussed that fire doors are regulated to be closed at all times. LPA informed Administrator if wished to be open, an automatic door holder will need to be installed connecting to the fire system.

As a result of today's observations, deficiencies were cited for violation of CCR Title 22, Chapter 8.

Exit interview and a copy of the report and appeal right provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/01/2024 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ABUNDANT LOVE AND CARE FOR THE ELDERLY
FACILITY NUMBER: 347005215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2024
Section Cited
CCR
87307(d)(6)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
-Licensee removed all items in the pathway immediately.
-Licensee is to submit a statement of compliance understanding that all outdoor and indoor passageways and stairways shall be kept free of obstruction.

POC is due to LPA via fax or email on 8/9/2024.

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

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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2