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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701013
Report Date: 08/05/2025
Date Signed: 08/05/2025 03:53:54 PM

Document Has Been Signed on 08/05/2025 03:53 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ABUNDANT PEACEFACILITY NUMBER:
342701013
ADMINISTRATOR/
DIRECTOR:		BARBARA HALL WILLIAMSFACILITY TYPE:
740
ADDRESS:19 SYNTHIA COURTTELEPHONE:
(916) 856-6464
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 6DATE:
08/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:37 PM
MET WITH:Barbara Hall WilliamsTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 08/05/2025, to conduct a case management visit. LPA Lee met with Facility’s Designated Administrator (FDA) Barbara Hall Williams and explained the purpose of the visit.

The purpose of this visit was to follow up on deficiencies identified during complaint investigation control # 27-AS-20250731120824. During the investigation, it was discovered through an interview with FDA Williams that she had provided false or misleading information regarding an incident on July 10, 2025, involving Resident 1 (R1), who had experienced a fall. Initially, FDA Williams stated she had gone for a walk lasting approximately five minutes and returned to the facility upon seeing EMTs on-site, with whom she stated that she had spoken to. However, when LPA Lee and Ombudsman Byron Toliver questioned the timeline of the incident, FDA Williams admitted to providing a false statement. She then corrected her account, stating that she had left the facility at approximately 10:46 PM and returned around 11:56 PM, resulting in a period of approximately 1 hour and 10 minutes during which no care staff were present. Upon her return, FDA Williams was informed by R1 and other residents that R1 had fallen and had been unable to get up. Further investigation revealed that no staff were available to provide assistance or contact emergency services during this time. Resident 2 (R2) then called EMT, who responded (exact arrival time unknown) and assisted R1 back into bed.

Additionally, it was determined through interviews and a review of records that this incident was not reported to the Community Care Licensing Division or to R1’s responsible party (RP), as required. Upon request to review R1’s file, FDA Williams was unable to produce any documentation for R1.

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: 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.

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)
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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: 08/05/2025
NARRATIVE
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During the visit, R1’s responsible party (RP) arrived at the facility, and FDA Williams attempted to work with RP to complete the necessary facility documents for R1. Per R1’s Responsible Party (RP), the RP will take the licensing documents to complete the paperwork. The RP also stated that they will request assistance from R1’s social workers in completing the documents and will return a copy to the facility once completed. Moreover, FDA Williams acknowledged that her husband (DW) regularly visits the facility about six time and they will sit outside to eat despite knowing that DW is not being associated with the facility.

An immediate $500.00 civil penalty was assessed on August 05, 2025; based on interview, the administrator did not provide care and supervision in violation of California Code of Regulations Section 87464(f)(1). A $600.00 civil penalty was assessed on August 05, 2025, based on interview, the administrator did not adhere to personnel requirements/background association of DM who comes to the facility six times in violation of California Code of Regulations Section 87355(e).

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the LIC 809- D page. An exit interview was conducted with FDA Williams and a copy of the LIC 809 report, LIC 809-D page, and appeal rights were given to FDA Williams.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/05/2025 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 08/05/2025 at 02:47 PM
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: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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License/Administrator to submit a written care plan on how the facility will provide adequate care and supervision for residents in care. Licensee/Administrator will also conduct in-service training on basic services and provide training documents used, and staff sign in sheet.
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Based on interviews, the licensee did not ensure care and supervision needs were provided on July 10, 2025, when the administrator left the facility resulted in absence of care and supervision for longer than 1 hour 10 minutes. This poses/posed an immediate health and safety risks to residents in care
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A statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit the care plan and statement to Licensing by POC due date of 08/12/2025 end of day 5:00 PM.

Type A
08/12/2025
Section Cited
CCR87355(e)

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87355(e) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to the Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
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The License/Administrator will conduct in-service training on criminal record clearance and association and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee.
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Based on interviews and records reviews, the licensee/administrator did not ensure that the administrator’s husband (DW) is associated with the facility prior to visiting the facility on multiple occasions.
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The facility shall submit R1’s complete file for LPA Lee to review once completed and a statement to Licensing by POC due date of 08/12/2025 end of day 5:00 PM.
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: 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


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/05/2025 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 08/05/2025 at 02:55 PM
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: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2025
Section Cited
CCR
87207

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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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License/Administrator will provide a statement of acknowledgement of reading and understanding the regulation cited by POC due date of 08/19/2025 end of day 5:00 PM.
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Based on interviews, the administrator provided false statements to LPA Lee and Ombudsman Toliver. This poses/posed a potential health and safety risks to residents in care.
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Type B
08/19/2025
Section Cited
CCR87405(d)(2)

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87405(d)(2) Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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License/Administrator will provide a statement of acknowledgement of reading and understanding the regulation cited by POC due date of 08/19/2025 end of day 5:00 PM.
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Based on interviews and records reviews the administrator did not conform to title 22 regulations when administrator left residents in care unsupervised, incidents reports are not reported to CCLD and responsible party, providing false statement and allowing an individual at the facility without being associated to the facility. This poses/posed a potential health and safety risks to residents in care.
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/05/2025 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 08/05/2025 at 02:58 PM
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: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2025
Section Cited
CCR
87211(a)(1)(D)

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87211(a) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified…
(D) Any incident which threatens the welfare, safety or health of any resident…

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The License/Administrator will conduct in-service training on reporting requirements and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading
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This requirement is not met as evidenced by:

Based on interviews and records reviews, the licensee/administrator is not reporting incident reports to CCLD. This poses/posed a potential health and safety risks to residents in care.
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and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit statement to Licensing by POC due date of 08/19/2025 end of day 5:00 PM.
Type B
08/19/2025
Section Cited
CCR87506(d)

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87506(d) Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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The License/Administrator will conduct in-service training on resident records and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and
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This requirement is not met as evidenced by:
Based on interviews and records reviews, the licensee/administrator did not ensure that R1 has a complete file on site for LPA Lee and Ombudsman Toliver to review. This poses/posed a potential health and safety risks to residents in care.
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understanding the regulation cited will also be provided to LPA Lee. The facility shall submit R1’s complete file for LPA Lee to review once completed and a statement to Licensing by POC due date of 08/19/2025 end of day 5:00 PM.
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: 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


LIC809 (FAS) - (06/04)
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