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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701013
Report Date: 08/05/2025
Date Signed: 08/05/2025 03:30:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250731120824
FACILITY NAME:ABUNDANT PEACEFACILITY NUMBER:
342701013
ADMINISTRATOR:BARBARA HALL WILLIAMSFACILITY TYPE:
740
ADDRESS:19 SYNTHIA COURTTELEPHONE:
(916) 856-6464
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Emi Kanaimuri and Barbara Hall WilliamsTIME COMPLETED:
12:37 PM
ALLEGATION(S):
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Staff did not assist resident in a timely manner.
INVESTIGATION FINDINGS:
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On August 05, 2025, Licensing Program Analyst (LPA) Pang Lee and Ombudsman Byron Toliver conducted an unannounced visit to initiate and conclude the investigation into the complaint allegation noted above. Upon arrival, LPA Lee and Ombudsman Toliver met with direct care staff Emi Kanaimuri and explained the purpose of the visit. LPA Lee requested that care staff Kanaimuri contact the Facility's Designated Administrator (FDA), Barbara Hall Williams. A brief phone interview was conducted with FDA Williams, who arrived at the facility approximately an hour later to participate in the visit. The facility census was six residents with 1 staff member present.

It was alleged that staff did not assist a resident in a timely manner. The investigation included interviews with FDA Williams and multiple residents. During an interview, FDA Williams admitted she did not provide timely assistance to Resident 1 (R1).

CONTINUED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20250731120824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/05/2025
NARRATIVE
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She stated that on July 10, 2025, at approximately 10:46 PM, she left the facility and returned around 11:56 PM. Upon her return, R1 and other residents informed her that R1 had fallen and was unable to get up. Further investigation revealed that no other care staff were present during this time, leaving the residents unsupervised. As a result, no staff were available to call emergency services. Resident 2 (R2) called EMT, who arrived (exact time unknown) and assisted R1 back into bed. Interviews with six out of six residents confirmed that staff were not present during the incident and that R2 had to call EMT for assistance. Based on observations and statements gathered during the investigation, the LPA was able to corroborate the allegation.

Due to this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with FDA Williams and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250731120824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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The Administrator has agreed to conduct an in-service training on Incidental Medical and Dental Care. As part of the Plan of Correction (POC), the Administrator will provide LPA Lee with the following documentation: Training materials used during the session,
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This requirement was not met as evidenced by:

Based on interviews conducted, Administrator Williams did not assist Resident 1 (R1) in a timely manner after R1 experienced a fall and was unable to get up.
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 a sign-in sheet listing all staff members who attended the training and a written statement of acknowledgment confirming administrator have read and understood the cited regulation. The completed POC is due to LPA Lee by August 12, 2025, no later than 5:00 PM.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3