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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701091
Report Date: 06/17/2026
Date Signed: 06/17/2026 03:58:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2026 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260610140806
FACILITY NAME:ABOUNDING PEACE ELDERLY CARE IIFACILITY NUMBER:
342701091
ADMINISTRATOR:UNA WAQALALAFACILITY TYPE:
740
ADDRESS:5490 ENRICO BLVDTELEPHONE:
(916) 898-1793
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:15CENSUS: 12DATE:
06/17/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sera Nakalevu TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are falsifying the medication administration record (MAR).
Staff did not reorder residents medication timely causing resident to miss medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On June 17, 2026, at 2:30 PM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to initiate a complaint investigation and deliver complaint findings with the above allegations LPA Martinez met with Sera Nakalevu and explained the purpose of today’s visit.

During today's facility visit, LPA Martinez conducted interviews and obtained facility records. Based on record review, it was learned that resident 1 (R1) was not administered Aspirin 81 MG, Omeprazole 20 MG, and Losartan 25 MG as needed. The facility did not refill R1's medication in a timely manner. As a result, R1 was not administered their medications from June 01, 2026 to June 09, 2026. It was also learned that R1's May and June 2026 medication administration records (MAR) were falsified. The May and June MARs indicated that facility staff administered ticagrelor and aspirin to R1. However, R1's did not have a supply of ticagrelor and aspirin in May and June 2026. Additionally ticagrelor and aspirin was discontinued on December 14, 2025.
Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20260610140806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ELDERLY CARE II
FACILITY NUMBER: 342701091
VISIT DATE: 06/17/2026
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
As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations.

An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights documents were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260610140806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ELDERLY CARE II
FACILITY NUMBER: 342701091
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465(a)(4) Incidental Medical and Dental Care:A plan for incidental medical and dental care shall be developed by each facility.the licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility staff agreed to conduct a in-service training on medication refills and maintaining Medication Administration Records by POC date 07/01/2026. Facility staff agrees to email in-service training to LPA Martinez by 07/01/2026 by 5:00 PM. In addition, the in-service training must be conducted by an
8
9
10
11
12
13
14
Based on observation, file review, interview, the Licensee did not ensure to assist R1 with refilling medication and assisting R1 with medication administration. This posed a potential health and safety risk to R1.
8
9
10
11
12
13
14
medical professional.
Type B
07/01/2026
Section Cited
CCR
87207
1
2
3
4
5
6
7
87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility staff agrees to conduct a Good character and a continuing reputation of personal integrity in-service training for all staff by POC date:07/01/2026. Facility staff agrees to email in-service training to LPA Martinez by 07/01/2026 5:00 PM.
8
9
10
11
12
13
14
Based on observation, interview, and file review. Facility employees disseminated false statement indicating that ticagrelor and aspirin was administered to R1 when it was not. This posed a potential health and safety risk to R1.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3