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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700899
Report Date: 01/11/2024
Date Signed: 01/16/2024 10:49:40 AM


Document Has Been Signed on 01/16/2024 10:49 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joyce MabungaTIME COMPLETED:
01:30 PM
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Unannounced annual visit made out to this facility on 01/11/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregivers, Kherjee Reyes 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 this LPA was conducting this annual visit. A brief interview was conducted with the facility designated Administrator at this time.
Current census was (5) residents.
This facility does have an approved hospice waiver to accept and retain up to (2) hospice residents at any given time.
It was learned that there weren't any residents under the care of hospice at this 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FRUITFUL HUMBLE ABODE
FACILITY NUMBER: 392700899
VISIT DATE: 01/11/2024
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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 08/16/2023 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.
A review of (5) facility resident files was conducted on the following LIC 858.
A review of (5) facility staff files was conducted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:
  1. LIC 308
  3. LIC 400
  5. LIC 500
  7. LIC 610

There weren't any deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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