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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701174
Report Date: 06/10/2026
Date Signed: 06/10/2026 04:46:45 PM

Document Has Been Signed on 06/10/2026 04:46 PM - 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:ABOUNDING PEACE III ELDERLY CAREFACILITY NUMBER:
342701174
ADMINISTRATOR/
DIRECTOR:		WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:10339 SAGRES WAYTELEPHONE:
(916) 667-8465
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 5DATE:
06/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Esther Tabua, Assistant AdministrtorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On June 10, 2026, Licensing Program Analysts Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPAs met with the assistant administrator, Esther Tabua (S1) and stated the purpose of the visit. The administrator, Unaisi Wagalala (AD) was notified and stated she is not feeling well today and designated S1 to assist with the annual and sign this report.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory. Facility has a clearance for 1 bedridden room (Room #5 on the facility sketch). Facility does not have clearance for delayed egress, and locked exterior/interior.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident units, resident bathrooms, dining room and outdoor areas.

LPA and S1 inspected 5 of 5 resident bedrooms and 3 of 3 bathrooms. Hot water temperature was measured at 108 to 110 degrees Fahrenheit. During inspection of the bathrooms, LPA observed one of the bathroom (next to Room #1), the shower tub does not have a grab bar installed, and cleaning solutions and sprays were observed under the sink (photo taken) – accessible to residents. The bathroom at the other hallway, next to Room #3, one of the grab bars was loose and the doorknob was observed to be taped which prevents residents from locking the bathroom for privacy (photo taken); also in this bathroom, LPA found a cleaning spray (photo taken) in the medicine cabinet, accessible to residents in care.

Inside Room #4, LPA observed a cleaning spray (photo taken) and next to it was Pepto Bismol (photo taken); the bedside table, LPA observed a bottle of Multivitamin (photo taken). This room belongs to resident (R5). Per review of R5’s Medical Assessment (LIC602A) dated 8/23/25, R5 is not able to administer own medications. This room can be accessed by other residents who per their LIC602As, they were assessed to be at risk if they have direct access to cleaning solutions, vitamins, and other similar and dangerous items.

Per observation, S1 immediately put away these items as instructed by LPA Villanueva.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2026
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: ABOUNDING PEACE III ELDERLY CARE
FACILITY NUMBER: 342701174
VISIT DATE: 06/10/2026
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Hallway temperature was maintained at 72 degrees Fahrenheit during this visit. Fire door was observed to be closed. Advisory was provided to rearrange their couch in the family room because it was observed to be partially blocking the exit door to the backyard (photo taken).

In the kitchen area, LPAs observed at least 7-day nonperishable and 2-day perishable food supplies. Refrigerator and freezer were within regulatory temperature. Knives/sharps were locked in a drawer. Fire extinguishers observed and last serviced on 3/31/2026. Smoke detectors were observed throughout and at least one carbon monoxide detector was observed. Medication cabinet was observed to be locked and not accessible to residents.

Outdoor area was inspected. One of the walkways was observed to be obstructed by plants (photo taken). Fences were observed to be in good repair at this time. One of the exit gates needs to be repaired as the bottom was dragging as LPA tried to open it. No bodies of water were observed at this time. There is a shaded area for outdoor activities. LPA observed outdoor furniture. S1 was unsure of the location of all shut-off valves; S1 was able to locate the electric panel. S1 was unsure how to operate the gas and water. Advisory was provided to ensure all staff know the location of each of the shut-off valves and know how to operate each one in case of emergency.

Record Reviews: Review of 5 of 5 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. During this review, LPA did not observe PRN Authorization Letter for each of the residents. Also, LPA noted that the residents with restricted health conditions do not have restricted health care plan in place. Additional review is needed.

Medication review was conducted for 1 resident at this time, including review of resident’s medication, PRN authorization letter, prescription records, Centrally Stored Medication Records, and Medication Administration Records. Additional review is needed.

Review of 3 staff files included but not limited to background clearance, first aid/CPR certification, and training. Per review of Guardian and LIS, staff on duty during this visit (S2) was not associated at this facility. Per review of facility’s Personnel Report (LIC500) dated 5/18/2026, S2 has been working at this facility since May 15, 2026. During this visit, the AD associated S2 to this facility. LPA rechecked Guardian to confirm.

Based on today's visit, this annual will require a continuation. A follow up visit will be conducted at a later date.

Deficiencies observed during today's visit will be cited on the next visit. Exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026
LIC809 (FAS) - (06/04)
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