392701209-11-28-2023-27-AS-CYAG-CXZP2N-20231128095613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701209
Report Date: 11/22/2023
Date Signed: 11/28/2023 09:56:21 AM

Document Has Been Signed on 11/28/2023 09:56 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 ABODE I		FACILITY NUMBER:	392701209
ADMINISTRATOR:	MABUNGA, JOYCE MAE S		FACILITY TYPE:	740
ADDRESS:	16378 ADOBE WAY		TELEPHONE:	(415) 619-9510
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY:	6	CENSUS: 5	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joyce Mabunga		TIME COMPLETED:	01:00 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 11/22/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Sheram Amparo, who was requested by this LPA to go ahead and contact the facility designated Administrator Joyce Mabunga to inform her that CCL was present at this time to conduct the annual visit. The facility designated Administrator Joyce Mabunga arrived shortly thereafter and was briefly interviewed at this time. Current census was 5 residents. It was learned that there was a resident under the care of hospice at this time. This facility does have a hospice waiver for (4) residents at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Joyce Mabunga. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 07/24/2024 with certificate # 6056435740. 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. This LPA did observe an additional food storage unit which was present and functional at this time in the garage area. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the hallway closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRUITFUL HUMBLE ABODE I	FACILITY NUMBER: 392701209
	VISIT DATE: 11/22/2023

NARRATIVE

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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Garage area was toured. This area housed additional furniture and supplies for the facility residents.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguisher, located in facility kitchen area, was observed to have been annually reviewed on 08/16/2023 by the local fire extinguisher company, Armor Fire Extinguisher, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (5) facility resident records was conducted and noted on the following LIC 858 form.
A review of (4) facility staff records was conducted and noted on the following LIC 859 form.

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

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 Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 09:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRUITFUL HUMBLE ABODE I	FACILITY NUMBER: 392701209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [4] facility care staff did not have an updated LIC 503, Health Screening, that was completed (6) months prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a review of all facility care staff files will be conducted to make sure that all Health Screening reports are updated and completed. A statement of correction, along with copies of updated LIC 503, will be completed and submitted into CCL by the due date.

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: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 09:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRUITFUL HUMBLE ABODE I	FACILITY NUMBER: 392701209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 [2] out of [2] facility restroom faucets delivering hot water was measured at 137.3 and 137.4 degrees respectively which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the hot water heater will be turned down immediately and the hot water will be measured daily for the next 7 days. A statement of correction, along with the 7-day log of hot water measurements, will be completed and submitted into CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 09:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FRUITFUL HUMBLE ABODE I	FACILITY NUMBER: 392701209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2023

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 the living area sliding glass door was missing a window screen and other window screens were in need of cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the sliding glass door windows screen will be replaced to have one. The other facility window screens will be cleaned and maintained to be in compliance at all times. A statement of correction, along with pictures of replaced sliding glass window screen and other cleaned window screens, will be completed and submitted into CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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