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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700899
Report Date: 05/25/2021
Date Signed: 12/07/2021 09:42:32 AM

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:FRUITFUL HUMBLE ABODEFACILITY NUMBER:
392700899
ADMINISTRATOR:MABUNGA, JOYCE MAEFACILITY TYPE:
740
ADDRESS:1849 COIT STREETTELEPHONE:
(415) 619-9510
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:6CENSUS: 3DATE:
05/25/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Joyce MabungaTIME COMPLETED:
04:30 PM
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Unannounced annual visit made out to this facility on 05/25/2021 by LPA Yang and was met by the facility Licensee/designated Administrator, Joyce Mabunga, who was briefly interviewed.
It was learned that there weren't any residents under hospice care at this time and this facility does have an approved hospice waiver for (2) residents.
Current census was 3 residents. Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time stored in the pantry area.
Garage area was toured and observed to be utilized as main storage unit at this time with unused furniture and other items for resident use. It was learned that all food supplies were purchased about two to three times a week by the facility Licensee/designated Administrator.
Resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured. Grab bars and non skid mats were observed to be present and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet was reviewed and observed to contain a sufficient supply of blankets, bed coverings, and towels to meet the needs of the residents at this time.
Living room, dining room and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Medication cabinet, located in the hallway leading to the garage, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the hallway cabinet leading to the garage, was observed to contain all of the required components at this time.
Fire extinguishers (2) were observed to have been annually purchased with a receipt attached revealing a purchase date of 08/22/2020 and in compliance at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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: FRUITFUL HUMBLE ABODE
FACILITY NUMBER: 392700899
VISIT DATE: 05/25/2021
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Exterior grounds of this facility were reviewed.
The perimeter fence, side gates, and all exits were reviewed and observed to be in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC809 (FAS) - (06/04)
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