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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700899
Report Date: 01/17/2025
Date Signed: 01/21/2025 09:51:16 AM

Document Has Been Signed on 01/21/2025 09:51 AM - 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:FRUITFUL HUMBLE ABODEFACILITY NUMBER:
392700899
ADMINISTRATOR/
DIRECTOR:		MABUNGA, JOYCE MAEFACILITY TYPE:
740
ADDRESS:1849 COIT STREETTELEPHONE:
(415) 619-9510
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 4DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joyce MabungaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 01/17/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility caregivers, Kherjee Reyes and Zenaida Pranada, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. The back up Administrator, Pedro Pancho, arrived shortly thereafter to this facility.
Current census was 4 residents. It was learned that there was (1) resident under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (2) residents under the care of hospice at any given time.
It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there was (1) resident diagnosed with dementia at this time.
It was learned that there was (1) resident receiving services through home health at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured.
Garage area was toured.
Laundry area, located in the room next to the living room, was toured and observed to be locked at this time. A review of the bleach, detergent, and all other cleaning supplies was conducted to make sure that they were locked and made inaccessible to the residents at this time.
Administrator certificate, # 7073274740, for Joyce Mabunga was observed to have an expiration date of
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: FRUITFUL HUMBLE ABODE
FACILITY NUMBER: 392700899
VISIT DATE: 01/17/2025
NARRATIVE
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07/12/2026 and in compliance at this time.
Medication cabinet, located in the facility kitchen drawers, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the medication cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher located hanging on the wall adjacent to the kitchen was observed to have been annually inspected by the local fire extinguisher company, Touch Down Fire, with the inspection date of 09/10/2024 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (3) facility personnel records was conducted on the LIC 859.
A review of (4) facility resident records was conducted on the LIC 858.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
A civil penalty in the amount of $100 was issued on the following LIC 421 BG at this time.
Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 09:51 AM - It Cannot Be Edited


Created By: Charlie Yang On 01/17/2025 at 11:58 AM
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: FRUITFUL HUMBLE ABODE
FACILITY NUMBER: 392700899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility care staff did not have an updated LIC 503, Health Screening, that indicated that the facility staff was properly cleared for TB which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2025
Plan of Correction
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The facility designated Administrator stated that a review of all facility care staff files will be conducted to make sure that all Health Screening reports are updated and completed to show proper clearance for TB at all times. A statement of correction, along with copies of updated LIC 503, will be completed and submitted into CCL by the due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/21/2025 09:51 AM - It Cannot Be Edited


Created By: Charlie Yang On 01/17/2025 at 11:58 AM
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: FRUITFUL HUMBLE ABODE
FACILITY NUMBER: 392700899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility care staff did not have proper transfer, and association, of fingerprint clearance to this facility which poses a threat to the health, safety and personal rights to all persons in care.
POC Due Date: 01/18/2025
Plan of Correction
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The facility designated Administrator stated that a review of all facility care staff files will be conducted to make sure that all present care staff are properly fingerprint cleared and associated to this facility at all times. A statement of correction, along with copies of updated fingerprint transfers, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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