392701498-9-9-2025-27-AS-CYAG-DLCN6S-20250909101137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701498
Report Date: 09/03/2025
Date Signed: 09/09/2025 10:11:47 AM

Document Has Been Signed on 09/09/2025 10:11 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 II		FACILITY NUMBER:	392701498
ADMINISTRATOR/ DIRECTOR:	PANCHO, PEDRO		FACILITY TYPE:	740
ADDRESS:	15345 ROSELLA WAY		TELEPHONE:	(415) 619-9510
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY: 6		CENSUS: 4	DATE:	09/03/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Joyce Mabunga		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 Post Licensing visit made out to this facility on 09/03/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Joyce Mabunga, to inform her that CCL was present at this time for the post licensing visit. Current census was 4 residents. It was learned that there were (2) 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 there were (2) residents diagnosed with dementia at this time. It was learned that there weren't any residents receiving services through home health at this time. This facility does have a bedridden fire clearance to be able to accept and retain up to (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, 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.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

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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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)

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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 II	FACILITY NUMBER: 392701498
	VISIT DATE: 09/03/2025

NARRATIVE

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Laundry room was toured at this time. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, # 7026619740, for Pedro Pancho was observed to have an expiration date of 10/26/2025 and in compliance at this time.
Forms and documents were being updated in order to renew this Administrator certificate at this time.
Medication cabinet, located in the facility hallway cabinets, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the kitchen area, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers (2) were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, Touch Down Fire Company, on 09/10/2024 and found 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.
A review of (4) facility personnel records was conducted and noted on the following LIC 859.
A review of (4) facility resident records was conducted and noted on the following 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

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/09/2025 10:11 AM - It Cannot Be Edited

Created By: Charlie Yang On 09/03/2025 at 12:41 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 II	FACILITY NUMBER: 392701498
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87208(a)

The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. 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 garage area was converted into a staff room with (2) beds present to accommodate live-in staff which was originally not fire cleared as a staff room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2025
	Plan of Correction
1 2 3 4	The facility Licensee stated that the garage area will be cleared of all beds and items designated for staff use and return it back to the original set up as the facility garage only. A statement of correction, along with a recent photo of the cleared garage area, 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.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

LIC809 (FAS) - (06/04)

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