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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701498
Report Date: 01/06/2025
Date Signed: 01/07/2025 09:01:38 AM

Document Has Been Signed on 01/07/2025 09:01 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 IIFACILITY NUMBER:
392701498
ADMINISTRATOR/
DIRECTOR:		PANCHO, PEDROFACILITY TYPE:
740
ADDRESS:15345 ROSELLA WAYTELEPHONE:
(415) 619-9510
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 0DATE:
01/06/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joyce MabungaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 01/06/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Pedro Pancho and Joyce Mabunga, who were briefly interviewed at this time.
Current census was 0 residents.
It was learned that this facility will be looking to accept and retain 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 (6) 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 this facility has a program to be able to accept and retain (1) bedridden resident at any given 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.
Laundry area, located in the room across from the garage, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. The door leading into the laundry room was observed to also have a lock that would make it inaccessible to the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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 2
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 II
FACILITY NUMBER: 392701498
VISIT DATE: 01/06/2025
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Administrator certificate, # 7026619740, for Pedro Pancho was observed to have an expiration date of 10/26/2025 and in compliance at this time.
Medication cabinets, located in the facility kitchen cabinets, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the medication closet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher was located in the facility kitchen area and observed to have been inspected on 09/10/2024 by the local fire extinguisher company, Touch Down Fire Inc., and observed to be 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.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
Facility resident files were observed to be present and set up at this time.
Facility personnel files were observed to be present and set up at this time.

Component III was waived and not conducted since this Applicant has been licensed for (2) other facilities at this time.

This facility was found to be in compliance at this time.

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

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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