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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701013
Report Date: 10/29/2021
Date Signed: 10/29/2021 03:26:27 PM

Document Has Been Signed on 10/29/2021 03:26 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ABUNDANT PEACEFACILITY NUMBER:
342701013
ADMINISTRATOR:GANT, MURPHYFACILITY TYPE:
740
ADDRESS:19 SYNTHIA COURTTELEPHONE:
(916) 856-6464
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 0DATE:
10/29/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Murphy GantTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived announced to conduct a Pre-licensing visit on 10/29/21 at 1:00PM.

LPA met with Murphy Gant, Applicant and stated the purpose of todays visit. The facility will be licensed for a capacity of 6 non-ambulatory residents.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed rooms to have required furniture. LPA did not observe residents during this visit.

Although there were no residents, LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 109.5*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Component III conducted-Licensure pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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