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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701209
Report Date: 12/04/2023
Date Signed: 12/05/2023 01:41:31 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 IFACILITY NUMBER:
392701209
ADMINISTRATOR:MABUNGA, JOYCE MAE SFACILITY TYPE:
740
ADDRESS:16378 ADOBE WAYTELEPHONE:
(415) 619-9510
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:6CENSUS: 5DATE:
12/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Joyce MabungaTIME COMPLETED:
02:00 PM
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Unannounced Plan of Correction 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.
The purpose of this visit was to follow up on the deficiencies and Plan of Correction that was set from a prior annual visit conducted on 11/22/2023. The following Plan of Correction was expected to be completed and submitted into CCL by the due date:

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.

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).

All window screens shall be clean and maintained in good repair.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (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
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A review of the Plan of Correction was conducted. Letters for clearances were printed and a copy was left with the facility designated Administrator at this time.

No further deficiencies cited at this time.

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