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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701013
Report Date: 10/21/2025
Date Signed: 10/21/2025 02:50:51 PM

Document Has Been Signed on 10/21/2025 02:50 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:
10/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Mereisi Naisausau and Veresa Taqasi TIME VISIT/
INSPECTION COMPLETED:
03:08 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 10/21/2025, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced annual inspection at the above-referenced facility to evaluate compliance with California Code of Regulations, Title 22. Upon arrival, LPA met with care staff Mereisi Naisausau and explained the purpose of the visit. LPA requested that the facility designated administrator (FDA) be contacted to notify the Community Care Licensing Division (CCLD) presence. Care staff stated she did not know who the current administrator was and reported that she had been scheduled to work at the facility by an individual named Charles (last name unknown). Approximately two hours later, Veresa Taqasi arrived and identified himself as the Assistant Administrator. He provided the staff files for Mereisi Naisausau and Luisa Biu. The census is 6 with 1 staff.

The facility is a single-story building licensed to serve six non-ambulatory residents, with hospice waiver approval for two residents. LPA conducted an inspection of the physical plant, including the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garage, and outdoor courtyards. The facility was observed to be clean and free of odor but was observed not in good repair due to broken tiles in the kitchen that posed a tripping hazard. There was no incontinence odors observed during the inspection. Resident bedrooms were properly furnished with appropriate bedding and adequate lighting. No bodies of water were present on the premises. The kitchen contained a sufficient supply of food, including a seven-day supply of non-perishable items and a two-day supply of perishable items. The hot water temperature measured in a resident bathroom sink was 113.4 degrees Fahrenheit, which is within the regulatory range of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mats in the bathrooms were stable and in good condition.

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: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
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: 10/21/2025
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
 Smoke and carbon monoxide detectors were operational and compliant with fire safety regulations. A fire extinguisher located in the common area was last serviced on 05/12/2025. The facility thermostat was observed to be set at 72 degrees Fahrenheit. A public telephone was located in the kitchen. During the garage inspection, the door was found to be unlocked, and multiple toxic substances were accessible to residents. These included multipurpose cleaner, tire shine spray, five paint cans, two toilet bowl cleaners, a Comet deodorizing cleanser, and a super oxygen bathroom cleaner. Sharp knives were properly stored and locked away, making them inaccessible to residents. Medication storage was found to be unlocked and accessible to residents, which is not in compliance with regulations. LPA reviewed medication for 3 of the 6 residents along with their Medication Administration Records (MAR), and the documentation was completed. The first aid kit was checked and found to contain the required components. LPA reviewed all 6 resident files, which were complete and up to date. 3 staff files were reviewed and found to be complete. A review of criminal record clearances indicated that all facility staff and individuals requiring caregiver background checks were fingerprint cleared and associated with the facility.

During the visit, LPA addressed concerns regarding the facility’s administrator. Assistant Administrator Taqasi stated that Filipe Naikas is the new administrator; however, LPA was unable to verify Filipe Naikas as an administrator associated with the facility in CCLD records. It was learned that Administrator Barbara Williams had not been present at the facility following an incident related to complaint control number 27-AS-20250731120824 and a case management visit dated 08/ 05/ 2025. This matter is currently under follow-up as part of complaint control number 27-AS-20251015132407. LPA also informed Assistant Administrator Taqasi that the facility’s annual fees were due and provided the PIN number for payment.

The following documents will be emailed to LPA by 10/31/2025 at the end of day 5:00 PM:



(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report

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: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
Page: 3 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: 10/21/2025
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
During today’s visit it was brought to LPA Lee’s attention that there were no staff on site on 10/20/2025 at approximately 5:00 PM. Based on interviews with residents in care, facility staff and residents family it is unclear whether staff were in the facility or not. Statements from residents, staff and residents’ families are contradictory.

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Assistant Administrator Veresa Taqasi, 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: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/21/2025 02:50 PM - It Cannot Be Edited


Created By: Pang Lee On 10/21/2025 at 01:39 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: 10/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation during the garage inspection, the door was found to be unlocked, and multiple toxic substances were accessible to residents. These included multipurpose cleaner, tire shine spray, five paint cans, two toilet bowl cleaners, a Comet deodorizing cleanser, and a super oxygen bathroom cleaner. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2025
Plan of Correction
1
2
3
4
The licensee will conduct storage space and access in-service training. Material used for training, staff sign in sheet and statement of acknowlegement of reading and understanding the regulation cited will be provided to LPA Lee by POC date 10/31/2025 end of day 5:00 PM.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations Medication storage was found to be unlocked and accessible to residents, which is not in compliance with regulations, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2025
Plan of Correction
1
2
3
4
The licensee will conduct Incidental Medical and Dental Care Services in-service training. Material used for training, staff sign in sheet and statement of acknowlegement of reading and understanding the regulation cited will be provided to LPA Lee by POC date 10/31/2025 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: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/21/2025 02:50 PM - It Cannot Be Edited


Created By: Pang Lee On 10/21/2025 at 01:39 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: 10/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observed the facility is not in good repair due to broken tiles in the kitchen that posed a tripping hazard. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2025
Plan of Correction
1
2
3
4
The licensee will conduct maintenance and operation in-service training and material used for training, staff sign in sheet and statement of acknowlegement of reading and understanding the regulation cited will be provided to LPA Lee by POC date 10/31/2025 end of day 5:00 PM. Per Assistant Administrator Taqasi who stated that he has already purchased tiles and that maintience will be on site today 10/31/2025 to start repair. POC will be cleared by visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


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