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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701209
Report Date: 11/07/2022
Date Signed: 12/05/2022 08:48:42 AM


Document Has Been Signed on 12/05/2022 08:48 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/16/2022 10:02 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

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This document is being amended due to incorrect final printing on the original document.
On 11/07/2022 at 9:50am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility announced to conduct a Pre-Licensing Visit. LPA Pascua met with Applicant, Joyce Mae D Mabunga and explained the purpose of the visit. The purpose of the visit was to conduct a pre-licensing for this facility. The administrator certificate for this facilities intended Administrator, Joyce Mae D Mabunga is active #6056435740 and expires on 07/12/2024. This facility will hold 6 elderly residents, 1 can be deemed bedridden, and 6 can be non-ambulatory. The facility also has a pending Dementia Plan on file. A brief interview with Joyce Mabunga was conducted. Current Census is 0.
At 10:00am, LPA Pascua initiated a tour of the facility with Joyce Mabunga.
The facility has a centralized screening point supplied with hand sanitizer and masks located by the entrance.
Five bedrooms were toured. There are 2 shared resident bedrooms, and 2 private bedrooms. An intended staff bedroom was also toured. Furniture and furnishings were observed to be present and in good condition for resident use.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible at this time.
Garage area was toured. LPA observed a large filing cabinet in which will store facility files.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. LPA observed that there was a sufficient amount of 2-day perishable and 7-day nonperishable food supplies available at this time. A fire extinguisher was also identified in the kitchen and was purchased on 10/15/2022.
A tour of the bathrooms was conducted. Grab bars were present and in good condition. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time to serve the residents.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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 I
FACILITY NUMBER: 392701209
VISIT DATE: 11/07/2022
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This facility will be using a medication closet which was located in the hallway. LPA observed the medication cabinet to be locked and made inaccessible at this time. First Aid was also present in the medication closet and contained all required components at this time.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and in compliance at this time.

Exterior grounds of this facility was toured. Perimeter fence and gates were inspected. LPA Pascua observed that there was no latch on the inside to open up the gate in case of emergency. LPA Pascua also observed that there was no delayed egress for the perimeter gate. Furthermore, the fire clearance did not specify if the facility is approved for delayed egress.

Pre-Licensing is incomplete. The following need to be completed in order to complete the pre-licensing visit:
· Fire clearance with approval for delayed egress.
· Install an inside latch that must be self-latching and self-closing on the emergency exit gate.

A follow up pre-licensing visit will be completed at a later date upon resolution of deficiencies.

Applicant has already conducted Comp I and Comp II.
Comp III will be waived at this time.

On 11/16/2022 at 10:00am, LPA Pascua conducted an announced follow-up visits to address the above deficiencies for this pre-licensing visit. The applicant has installed an inside latch on the gate that allows the gate to be self-latching and self-closing. The applicant has notified LPA that there is no delayed egress device. The pre-licensing deficiencies have now been resolved. Pre-Licensing is now complete.

Exit Interview was conducted and a copy of this report was given to Joyce Mabunga.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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