342701013-10-23-2025-27-AS-CACL-DN4MLC-20251104084206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701013
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:27:56 PM

Unsubstantiated

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
09/18/2025 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250918210117

FACILITY NAME:	ABUNDANT PEACE		FACILITY NUMBER:	342701013
ADMINISTRATOR:	BARBARA HALL WILLIAMS		FACILITY TYPE:	740
ADDRESS:	19 SYNTHIA COURT		TELEPHONE:	(916) 856-6464
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 6	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	11:46 AM
MET WITH:	Atelaite Peti and Vereas Taqasi		TIME COMPLETED:	01:11 PM

ALLEGATION(S):

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Staff do not provide care and supervision to resident resulting in resident being left on floor for extended periods of time.

Staff do not seek medical attention to resident in a timely manner.

Staff is mismanaging resident's medications.

INVESTIGATION FINDINGS:

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On 10/23/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Atelaite Peti and explained the purpose of the visit. LPA Lee was later met by Assistant Administrator Vereas Taqasi. The purpose of this visit is to deliver complaint finding for the allegation above. A brief interview conducted with care staff Peti. and Assistant Administrator Taqasi. The current census is six residents with one staff.

It was alleged that staff do not provide care and supervision to residents, resulting in residents being left on the floor for extended periods of time. The investigation included a review of records and interviews with staff, and residents in care. It was learned that Resident 1 (R1) had multiple incidents that led to hospital visits on 08/08/2025, 08/14/2025, 08/19/2025, 09/04/2025, and 09/11/2025. During interviews, three out of three staff members denied not providing care and supervision to residents that leaves residents on the floor for extended periods.

CONTINUED LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

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-20250918210117

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: 10/23/2025

NARRATIVE

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Additionally, all six out of six residents interviewed reported that when R1 experiences a fall, facility staff does assist in helping R1 up. None of the residents expressed concerns regarding staff not providing care and supervision to residents. Furthermore, R1 denied the allegation, stating that when falls occur, staff respond and provide assistance, and R1 is not left on the floor for an extended period of time. Based on records review and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation.

It was alleged that Staff do not seek medical attention to resident in a timely manner. The investigation included a review of records and interviews with staff and residents in care. The investigation revealed that on 09/15/2025, Resident 1 (R1) fell in the bathroom and hit their head on the toilet. During an interview, Staff 1 (S1) stated that they heard a noise, checked on R1, found R1 on the floor, and assisted R1 in getting up. In a separate interview, R1 confirmed that S1 assisted them after the fall and stated that they did not believe the incident was serious, therefore refusing medical treatment. Additionally, six out of six residents interviewed reported having no concerns regarding staff not seeking medical attention for residents in care in a timely manner. Based on records review and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation.

It was alleged that staff is mismanaging residents’ medications. The investigation included a review of records, as well as interviews with staff, residents in care, and the resident’s responsible party. During facility visits conducted on 09/22/2025 and 10/21/2025, LPA Lee reviewed the medications on hand for Residents 1 through 3 (R1–R3), along with their Medication Administration Records (MARs). The review found that all medications were complete and accurate, with no discrepancies observed. Interviews were conducted with three staff members, all of whom denied the allegation of medication mismanagement. Additionally, all six out of six residents interviewed stated that staff are administering medications and that they have no concerns regarding medication management. An interview was also conducted with R1’s responsible party (RP), who confirmed they had no concerns regarding R1’s medications at the facility. RP clarified that their concerns were related to the hospital from which R1 was discharged. It was learned that following R1’s hospital visits on 09/04/2025, R1 was discharged with additional medications and those medications was not present at the facility; therefore Assistant Administrator Taquasi called R1's RP to question the 11 medications.

CONTINUED LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20250918210117

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: 10/23/2025

NARRATIVE

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Based on RP’s discussion with R1’s primary care physician (PCP), RP followed R1’s PCP order of not refilling R1’s medications until R1 and RP meet with R1’s PCP to go over R1’s medications. RP reiterated that they had no concerns regarding the facility’s medication management or pharmacy services and confirmed that the issue originated with the hospital discharge process. Based on records review and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

An exit interview was conducted with care staff Peti, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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