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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701013
Report Date: 05/16/2025
Date Signed: 05/16/2025 11:45:36 AM

Document Has Been Signed on 05/16/2025 11:45 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/
DIRECTOR:		BARNES, STACIFACILITY TYPE:
740
ADDRESS:19 SYNTHIA COURTTELEPHONE:
(916) 856-6464
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 0DATE:
05/16/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Barabara WilliamsTIME VISIT/
INSPECTION 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
On 05/16/25, Licensing Program Analyst (LPA) Pang Lee arrived at Abundant Peace for the purpose of conducting a Case Management Inspection to address deficiencies observed on 11/26/24 during an annual inspection to ensure compliance prior to accepting any residents in care. LPA Lee met with care staff Barbara Williams who assisted with today’s visit.

LPA conducted a case management inspection to ensure there are no health and safety concerns. The facility is a single-story building licensed to serve six (6) non-ambulatory residents and approved for 2 hospices wavier. LPA Lee conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garage and outdoor courtyards, to ensure compliance with Title 22 regulations. The facility was observed to be clean and odor-free. The facility was not in good repair. LPA Lee observed exposure wires in the common area on both side of the television. Resident bedrooms were properly furnished with appropriate bedding and adequate lighting. No bodies of water were observed on the premises. During the kitchen tour, LPA Lee observed a sufficient supply of food, including a seven-day supply of non-perishable and a two-day supply of perishable items. The hot water temperature in the resident bathroom sink measured 111.2°F, which falls within the regulatory range of 105°F to 120°F. Grab bars and non-slip mats in the bathrooms were secure and in good condition. Smoke and carbon monoxide detectors were found to be operational and in compliance with fire safety requirements. The facility's fire extinguisher, located in the common area and was last serviced on 05/02/25. Two public telephone was observed in the common area and in the kitchen; however, there are no services. Required documents and posting were visibly displayed; however, PUB 475 needs to be in the size of 20” x 26".

Continued LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
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: 05/16/2025
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 facility thermostat was set to 69°F at the time of the inspection. Toxic cleaning agents were stored underneath the kitchen cabinet inaccessible to residents. Sharp knives were observed secured in a locked kitchen cabinet. The first aid kit was inspected and contained all required supplies. The facility has a designated lock area for residents Medications, residents and facility staff files. One staff file was reviewed and complete. Based on LPA’s walk through of the facility it was observed that one of the resident’s bedroom was switched with the staff room and did not aligned with the submitted facility sketch to the department. A review of staff records confirmed that all individuals requiring background checks were fingerprint cleared and associated with the facility. LPA Lee inspected the courtyard and observed the health and safety concerns. Ramps that were put in placed in the patio were observed not sturdy and a tripping hazard.

The following dependencies that were observed on 11/26/24 has not been corrected:

• The facility shall be in good repair. Exposed wires made accessible to residents.

• The Licensee shall remove the dried vegetation, branches and weeds.

• The following shall be posted and visible to residents in care: The Administrator's Certificate, facility sketch, the Local Ombudsman poster, CCLD complaint poster.

• Ramps in patio deck needs to be extended to prevent tripping hazards. Side rails need to be sturdy.

• Residents needs to have access to telephone

• The licenses will ensure that there are various activities made accessible to residents in care.

• Ensure all sheds are locked at all times.

• Garage will be de-cluttered and ensure all potential hazard are locked.

As a result of this case management, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with caregiver Barbara and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/16/2025 11:45 AM - It Cannot Be Edited


Created By: Pang Lee On 05/16/2025 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABUNDANT PEACE
FACILITY NUMBER: 342701013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2025
Section Cited
CCR
87307(d)(4)

1
2
3
4
5
6
7
87307(d)(4) Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(4) 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.
1
2
3
4
5
6
7
Licensee will ensure that the there are no tripping hazards, side rails will be added to the patio for safety of the residents and fence are to be sturdy. POC will be clear by visit. POC due by 05/23/25 end of day 5:00 PM.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

PA Lee observed ramps that were put in place in the patio were not sturdy and a tripping hazards. This posed an immediate risk to residents in care.
8
9
10
11
12
13
14
Type A
05/23/2025
Section Cited
CCR87311

1
2
3
4
5
6
7
87311 Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure to have telephone services on the premises. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.
8
9
10
11
12
13
14
LPA Lee observe telephone on the premises does not have services. This posed an immediate risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/16/2025 11:45 AM - It Cannot Be Edited


Created By: Pang Lee On 05/16/2025 at 11:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABUNDANT PEACE
FACILITY NUMBER: 342701013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2025
Section Cited
CCR
87212(c)

1
2
3
4
5
6
7
87212(c) Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will post emergency telephone numbers in the facility and made visible. Licensee will send LPA Lee pictures of the emergency telephone numbers being posted by 05/23/25 end of day 5:00 PM.
8
9
10
11
12
13
14
LPA Lee did not observe an emergency telephone number posted in the facility. This posed a potential risk to residents in care.
8
9
10
11
12
13
14
Type B
05/23/2025
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
1
2
3
4
5
6
7
Licensee will remove the exposed wires for the safety of the residents in care. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

LPA Lee observed exposed wires in the common area by the television. This posed a potential risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/16/2025 11:45 AM - It Cannot Be Edited


Created By: Pang Lee On 05/16/2025 at 11:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ABUNDANT PEACE
FACILITY NUMBER: 342701013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2025
Section Cited
CCR
87208(a)(7)(A)

1
2
3
4
5
6
7
87208 Plan of Operation
The licensee shall have and maintain a current, written definitive plan of operation for the facility…
(7) Sketches, showing dimensions, of the following:
(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents…
1
2
3
4
5
6
7
Licensee will ensure that the submitted facility sketch is maintained and accurate at all times. Licensee will review the submitted facility sketch and ensure that residents and staff room are switched and accurate. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

LPA Lee observed that one of the resident’s bedrooms was switched with the staff room based on observation and facility sketch that was submitted to the department. This posed a potential risk to residents in care.
8
9
10
11
12
13
14
Type B
05/23/2025
Section Cited
CCR87219(i)

1
2
3
4
5
6
7
87219(i) Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure that there are multiple activities and equipment made available to residents in care. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

8
9
10
11
12
13
14
LPA Lee did not observe multiple activities, equipment and supplies for residents. LPA Lee only observed books and a guitar. This posed a potential risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6