342701174-6-16-2025-27-AS-AVIA-DHPUUV-20250616155412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 06/16/2025
Date Signed: 06/16/2025 03:54:19 PM

Document Has Been Signed on 06/16/2025 03:54 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:	ABOUNDING PEACE III ELDERLY CARE		FACILITY NUMBER:	342701174
ADMINISTRATOR/ DIRECTOR:	WAQALALA, UNAISI		FACILITY TYPE:	740
ADDRESS:	10339 SAGRES WAY		TELEPHONE:	(916) 667-8465
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY: 6		CENSUS: 5	DATE:	06/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Staff on duty, Luisa Saqusaqu		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 6/16/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to conduct their required annual inspection. LPA met with staff on duty, Luisa Saqusaqu (S5) and stated the purpose of this visit. The Administrator, Unaisi Waqalala, was notified and informed she was unable to be present during this inspection. Present during today's visit were 4 residents in care with 1 staff on duty (S1). Upon arrival LPA observed one resident at a dining table near the entrance of the facility. Another resident in the living room watching TV then eventually went to their bedroom. Per S1, residents just finished their lunch. One resident was observed in their bedroom listening to music with their headphones. Another resident was observed to be sitting in their bedroom, who then went to the bathroom during the physical inspection. LPA evaluated the physical plant with S5 to ensure the health and safety of the residents in care. The facility is a one-story home located in a residential neighborhood. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clean and in good repair at this time. LPA inspected 5 of 5 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the hot water temperature in 1 of 2 resident bathroom to be 113 degrees Fahrenheit. Room temperature was observed at 82 degrees Fahrenheit upon arrival. LPA observed sufficient seven day non-perishable and two day perishable food supplies. One fire extinguisher was observed and were last inspected on 4/3/2025. Smoke and carbon monoxide detectors were observed and tested and found to be operable at this time. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. No bodies of water was observed at this time. Fireplace was observed to be screened and non-operational at this time. Exit doors have audible alarms. A medication box was observed inside the kitchen refrigerator and was found to be locked and not accessible to residents in care. Con't 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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 3

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 3

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: ABOUNDING PEACE III ELDERLY CARE	FACILITY NUMBER: 342701174
	VISIT DATE: 06/16/2025

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

Outdoor area was inspected. Facility has a covered porch equipped with outdoor furniture for resident use. Facility has 2 side gate exits. The right side of the facility (garage side), LPA observed the gate to be in disrepair as evidenced door stopper sticking out with nails exposed. The side fence has part of it with nails sticking out. Photos were sent to Administrator.

Review of 5 resident files (R1, R2, R3 R4, R5) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. One resident (R5) did not have their Admission Agreement on file available for review during this visit.

Review of 5 staff files (S1, S2, S3, S4, S5) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. It was noted that one staff (S4) was not associated to this facility. Record review of S4's training indicated that staff started on 11/15/2024. Additionally, it was discovered that S4's health screening was completed on 9/7/2023. Furthermore, review of S2's files revealed that S2 was associated to this facility on 5/30/25 and through interview with S3, S2 worked early in June 2025 to relieve S3. However, LPA discovered that S2's last health screen/TB test was completed on 6/19/2023.

Administrator to submit current Liability Insurance Certificate, LIC500 and LIC308 to the Department.

Based on today's visit, this annual will need continuation. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, following deficiencies were observed during today's visit:

R5 did not have their Admission Agreement on file available for review.
S2 did not have current Health Screening/TB test completed prior to working at this facility.
S4 is not associated to this facility but per review of their training record indicated that their start date was on 11/15/24.
Fence and side gate needs repair as evidence of nails sticking out.

Citations will be issued when this annual is completed. The Department will return at a later date to complete the annual inspection.

Exit interview was conducted and a copy of the report was provided upon exit.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3