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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002956
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:27:52 PM

Document Has Been Signed on 12/04/2024 03:27 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ABUNDO'S RESIDENTIAL CAREFACILITY NUMBER:
515002956
ADMINISTRATOR/
DIRECTOR:
ABUNDO, EMMANUELFACILITY TYPE:
735
ADDRESS:10191 HYACINTH WAYTELEPHONE:
(408) 348-3453
CITY:LIVE OAKSTATE: CAZIP CODE:
95953
CAPACITY: 4CENSUS: 2DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Emmanuel Abundo and Nick SosaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced visit. LPA toured the facility with the caregivers. Licensee and Administrator Emmanuel Abundo and Nick Sosa arrived during this visit and finished the visit with LPA. .
The facility has a fire clearance for three ambulatory and one non-ambulatory for a total four residents. This facility has four private bedrooms and one staff room. The main entrance opens to a small foyer. To the left of the main entrance is a nook that has a closet, desk, and door leading to the garage. The garage has a staff room. The staff room has a door leading to the private bathroom of the largest private room. The door has a lock on it preventing its use so staff cannot use the bathroom and the resident room as a pass-through. To the right of the main entrance is a hallway leading to three private resident rooms, laundry room, and full common bathroom. To the left of the main entrance and past the nook is a hallway that leads to the forth private resident room with its own full private bathroom. The main common, dining, and kitchen area is in the back. There is a sliding glass door in the back leading to the backyard. The backyard has a locked shed on the left side. There is a gate on the same side as the garage. There are several locked cabinets in the facility that is being used for confidential storage and items that are not accessible to residents.

Two staff records were reviewed
Two resident records were reviewed.

Multiple topics discussed.
The following shall be updated and submitted to licensing within 30 days;
LIC 500- facility personnel or staff schedule
LIC 308- designation of administrative responsibility
LIC 610- emergency disaster plan

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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