392700899-1-31-2023-27-AS-CYAG-CNLPQ9-20230131103048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700899
Report Date: 01/25/2023
Date Signed: 01/31/2023 10:30:53 AM

Document Has Been Signed on 01/31/2023 10:30 AM - 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:	FRUITFUL HUMBLE ABODE		FACILITY NUMBER:	392700899
ADMINISTRATOR:	MABUNGA, JOYCE MAE		FACILITY TYPE:	740
ADDRESS:	1849 COIT STREET		TELEPHONE:	(415) 619-9510
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	6	CENSUS: 5	DATE:	01/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joyce Mae Mabunga		TIME COMPLETED:	12:30 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	Unannounced annual visit made out to this facility on 01/25/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the facility caregivers, JoeRey Pastrana and Olivia Camanag. LPA Charlie Yang requested that the facility caregiver go ahead and contact the facility designated Administrator, Joyce Mae Mabunga, to inform her that CCL was present at this time. The facility designated Administrator, Joyce Mae Mabunga, arrived later to this facility while the LPAs were conducting this annual visit. Brief interview was conducted with the facility designated Administrator. Current census was (5) residents of which (2) are under the care of home health and (2) residents are under the care of hospice at this time. This facility does have an approved hospice waiver to accept and retain up to (2) hospice residents at any given time. Tour of the facility was conducted. Living area, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Knives and other sharp objects were observed to be locked and made inaccessible to the residents at this time. Food supply was reviewed to make sure that there was a sufficient amount of 2-day perishable and 7-day nonperishable quantities at all times. Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures for handling, dispensing, and documentation of the resident medications was discussed with the facility designated Administrator. Dispensing log was also reviewed along with the Medication Administration Record. A tour of the resident bedrooms was conducted. Furnishings and furniture were observed to be sufficient and maintained in compliance at this time. A tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at all times. Grab bars and non skid mats were observed to be present and in good repair at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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: FRUITFUL HUMBLE ABODE	FACILITY NUMBER: 392700899
	VISIT DATE: 01/25/2023

NARRATIVE

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A tour of laundry room was conducted. It was observed to be locked and made inaccessible to the residents at this time. Laundry detergent, bleach, and other cleaning agents were observed to be present as well.
A tour of the garage area was conducted. Additional supplies and items were present for resident use.
Linen closet, located in the dining area, was observed to be stocked with adequate towels, comforters, and sheets sufficient to meet the needs of the residents at this time.
First aid kit was observed to be present and contained all of the necessary components at this time.
Fire extinguishers (2), were located in the entry way and exterior patio area, and were observed to have been annually inspected on 09/27/2022 by the local fire extinguisher company, Armor Fire Extinguisher Company, and in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and all exits was conducted.
It was observed that this facility has an exterior shed in the backyard area. A review of the shed was conducted and observed to be locked and made inaccessible to the residents at this time.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

The appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/31/2023 10:30 AM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FRUITFUL HUMBLE ABODE	FACILITY NUMBER: 392700899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since (2) windows screens had holes, rips, or tears within them which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/01/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all window screens will be repaired/replaced to remove any holes, rips, or tears within them. A statement of correction, along with proof of contracted work for the repairs and pictures, will be completed and submitted into CCL for review by this LPA by the due date of 02/01/2023.

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in review of the storage pantry unit did not contain the required 7-day supply of nonperishable food items which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/01/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that additional food items for non perishable amounts will be purchased and a statement of correction, along with a copy of the food items receipt, will be completed and submitted into CCL for review by this LPA by the due date of 02/01/2023.

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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