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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701209
Report Date: 11/06/2024
Date Signed: 11/12/2024 09:32:51 AM

Document Has Been Signed on 11/12/2024 09:32 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 ABODE IFACILITY NUMBER:
392701209
ADMINISTRATOR/
DIRECTOR:		MABUNGA, JOYCE MAE SFACILITY TYPE:
740
ADDRESS:16378 ADOBE WAYTELEPHONE:
(415) 619-9510
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 6DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joyce MabungaTIME VISIT/
INSPECTION COMPLETED:
01:00 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
Unannounced Annual visit made out to this facility on 11/06/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Joyce Mae Mabunga, who was briefly interviewed at this time.
Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (4) 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 (3) 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.
Additional food storage units located in the garage area were observed to be present and functional at this time.
Laundry area, located in the room next to the garage, was toured and observed to not be able 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, # 6056435740, for Joyce Mabunga was observed to have an expiration date of
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 5
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 I
FACILITY NUMBER: 392701209
VISIT DATE: 11/06/2024
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
07/12/2024 and in compliance at this time. Forms and documents have been completed, notice of paid invoice on 06/24/2024, in order to renew this Administrator certificate at this time.
Medication cabinet, located in the facility hallway closet, 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 extinguishers were located throughout this facility and 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 (4) facility personnel records was conducted on the LIC 859.
A review of (6) 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.
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: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/12/2024 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/06/2024 at 12:23 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: FRUITFUL HUMBLE ABODE I
FACILITY NUMBER: 392701209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [4] facility care staff did not have an updated LIC 503, Health Screening, that was completed (6) months prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
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. 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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/12/2024 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/06/2024 at 12:23 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: FRUITFUL HUMBLE ABODE I
FACILITY NUMBER: 392701209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in [2] out of [2] facility restroom faucets delivering hot water was measured at 137.3 and 137.4 degrees respectively which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that the hot water heater will be turned down immediately and the hot water will be measured daily for the next 7 days. A statement of correction, along with the 7-day log of hot water measurements, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that the laundry room was unable to be locked and secured. This LPA observed that the detergents and cleaning supplies were not properly stored and secured in the cabinets which were able to be locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all cleaning supplies, detergents, and bleach will be removed and secured in the cabinets that are able to be locked and made inaccessible to the residents at all times. A statement of correction, along with photos of the cleared cleaning supplies, detergents, and bleach, 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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/12/2024 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/06/2024 at 12:23 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: FRUITFUL HUMBLE ABODE I
FACILITY NUMBER: 392701209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that [3] out of [6] facility residents files were incomplete. This LPA observed that the resident files were incomplete missing required dates and signatures on several forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility resident files will be reviewed and updated to contain all required signatures and dates on them. A statement of correction, along with copies of the updated forms and documents, will be completed and submitted into CCL by the due date.
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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5