392701209-12-5-2023-27-AS-CYAG-CY8TF7-20231205134105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701209
Report Date: 12/04/2023
Date Signed: 12/05/2023 01:41:10 PM

Document Has Been Signed on 12/05/2023 01:41 PM - 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:	12/04/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joyce Mabunga		TIME COMPLETED:	12:00 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 Post Licensing visit conducted out at this facility by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Joyce Mabunga, at this time. A brief interview was conducted with the facility designated Administrator. 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. 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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: 12/04/2023

NARRATIVE

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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.

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

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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