<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701013
Report Date: 11/16/2023
Date Signed: 11/16/2023 11:52:03 AM

Document Has Been Signed on 11/16/2023 11:52 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:ABUNDANT PEACEFACILITY NUMBER:
342701013
ADMINISTRATOR:BARNES, STACIFACILITY TYPE:
740
ADDRESS:19 SYNTHIA COURTTELEPHONE:
(916) 856-6464
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 0DATE:
11/16/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Marvin TibbitsTIME 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
An unannounced annual inspection was completed by Licensing Program Analyst (LPA) Pang Lee on 11/16/2023. LPA identified herself and the purpose of the visit to the licensee friend, Marvin Tibbitts and a brief interview followed with both Marvin and licensee Murphy Grant (via telephone). Administrator was not present during today's visit. The census at the time was 0.

The following Technical Assistance was provided during today's inspection. These concerns must be addressed, and Licensing must be contacted for an additional inspection prior to the admittance of any residents.

If Licensing is not informed, and the inspection is not completed prior to admitting any residents into care, Administrative Actions may be taken.

· All toxins shall be locked and inaccessible to residents in care.
· All sharp objects shall be locked and inaccessible to residents in care.
· All resident accommodation should include the required furniture: chest of drawers, bed, night stand, lamp/lighting sufficient for reading, and a chair.
· The facility shall be in good repair and all debris, broken appliances, furniture, medical equipment, bins, trash, suitcases, and other discarded items shall be removed from the facility's property. Broken tiles in the entry need to be repair or replace.
· The Licensee shall remove the dried vegetation, and weeds.
· The following shall be posted and visible to residents in care: The Administrator's Certificate, the Emergency/Disaster Plan with facility sketch, the Local Ombudsman poster, and the poster of Resident Rights.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 17
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: ABUNDANT PEACE
FACILITY NUMBER: 342701013
VISIT DATE: 11/16/2023
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
26
27
28
29
30
31
32
·The Licensee shall repair/replace any missing window screens or screens with holes.
· The licensee shall repair/replace the emergency exit gate that is not in good condition.
· The licensee shall ensure that the emergency gate is not lock at all times.
· All food items in the refrigerator, freezer, and pantry will be inspected and all expired items shall be disposed.
Going forward, any food item once opened shall be dated appropriately as will any leftovers.

· There shall be a designated space for personal items, for example, a change of clothes, handbags, coats, meals, medications, etc. Personal items shall not be stored in multiple bedrooms, drawers, or closets.


· Fire extinguishers need to be inspected annually. Last inspection date was 05/01/2021.
· There is light appropriate for the use of each room and sufficient to ensure the comfort and safety of all people in the facility. Resident bedroom #4 bathroom light is not in good repair. The light does not turn on.
· Resident bathrooms shall have non-skid mats at all times.
· The license will ensure residents room is not used for other individuals sleeping purposes.
· Licensee will ensure stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless
· well lighted.
· Licensee will ensure a telephone service is always on the premises.
· The licensee will ensure that personal records are maintained on the licensee, and administrator available upon request. Facility did not have a designated place for files.
· The licenses will ensure that there at activities made accessible to residents in care.
· The licensee will ensure that an emergency and disaster plan, evacuation procedures and facility sketch, emergency exiting plans and emergency contact information is posted in the facility.

There were no citations given today. A copy of this report was provided to the Licensee.

Exit interview.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 17 of 17