Abounding Peace Elderly Care II

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: ) The facility allowed excluded individuals to work in the facility. 2) Staff are forging resident documents. 3) The Administrator is not present at the facility for a sufficient amount of time.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at Abounding Peace Elderly Care II (RCFE) on 7/15/26 at 1:40pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Adi Lina and together discussed the investigation details. Based on files obtained and reviewed during the investigation process, LPA Gould was unable to corroborate the allegation. LPA reviewed 14 resident files. LPA requested and obtained physician reports (LIC 602) for all 14 residents in care (see confidential name list LIC-811 dated 7/15/26 ). LPA Gould reviewed reports for each resident. Upon review, the department has no concerns for 11 of the 14 physician reports are being altered or fraudulent. The files reviewed appear to be completed by the resident’s physician or an appropriately skilled professional that are able to complete the forms per department regulations. Report Continued on LIC 9099 Unsubstantiated Additionally, LPA conducted interviews with five staff members and five residents. All staff interviewed denied excluded individuals presence at the facility. Some staff members interviewed had no knowledge of the individuals. The five residents interviewed and due to cognitive impairments were unable to provide any substantive information related to the allegation. four of the five staff interviewed knew who the administrator is and identified her most recent date. LPA attempted interviews with five residents who were unable to provide substantive information due to cognitive impairments. Based on LPAs history with the facility and history of inspections, LPA has determined the facility administrator or their designee were present at approximately 80 percent of inspections within the last 12 months. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 27-AS-20260211141320

Type of visit: Case Management - Deficiencies

On 6/24/26 at 8:30am, Licensing Program Analyst (LPA) Kevin Gould conducted a case management deficiencies inspection to address deficiencies of facility operation while conducting an unannounced complaint investigation. LPA met with staff Sara . Upon entering the facility, LPA conduced a walk through of the facility. LPA inspected the facility fridge and observed supplies of insulin and needles stored in the side door of the fridge. Additionally, LPA observed lock boxes for medications in the fridge that were lot locked. LPA observed combination locks on both lock boxes and both were set to 0-0-0 and opened when LPA pressed the latch. LPA also observed unsecured cleaning supplies and sharp knives accessible to residents under the sink and in the sharp knives drawer. LPA asked staff member to lock items. Staff member attempted to lock items and eventually admitted the key for both locks is not at the facility and LPA observed the staff member transfer all items to a locked closet. Per the California Code of Regulations, Title 22, The following deficiencies are cited. An immediate civil penalty was also issued. Exit interview conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 26, 2026

Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by LPA observations of a resident medication stored in a fridge without a lock box and accessible to residents in care. LPA also observed two lock boxes that were not locked and stored in the common fridge which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: facility has agreed to conduct medication training for all staff who administer medications. Facility has agreed to conduct a 1 hour training on securing medications and ensuring items are stored, locked an inaccessible to residents.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jun 26, 2026

Storage Space and Access: Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of both cleaning supplies and sharp knives were unsecured and accessible to residents in care and staff member present admitted to LPA that the key to lock both items is not at the facility which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: Facility has agreed to change all locks for sharp knives and cleaning supplies from a key lock to magnetic lock to ensure the cabinet and drawer will automatically lock and will not rely on a key for ensuring the items are locked and secured. a copy of the order will be sent to LPA by the POC due date.

Allegation investigated: Staff are falsifying the medication administration record (MAR). Staff did not reorder residents medication timely causing resident to miss medication.

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 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.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 27-AS-20260610140806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 1, 2026

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: 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.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: 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 medical professional.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jul 1, 2026

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: 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.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: 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.

Type of visit: Required - 1 Year

On 4/17/26 at 11:40am Licensing Program Analyst (LPA) Kevin Gould arrived at Abounding Peace Elderly Care II for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Adi Lina and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed the closet door in bedroom 105 is in need of repair, an exterior door handle is in need of replacement and the side gate is in need of repair as it is barely hanging onto the post and is difficult to open. LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed facility staff are not disposing of syringes as required by regulations and disposing of syringes in municipal garbage bins. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Case Management - Deficiencies

On 2/12/26 at 9:30am, Licensing Program Analyst (LPA) Kevin Gould conducted a case management deficiencies inspection to address deficiencies of facility operation while conducting an unannounced case management inspection. LPA met with Administrator Una Waqalala. LPA observed the following: Expired canned goods and perishable food supplies such as milk and items that are required to be refrigerated after opening were stored in cabinet such as jelly and BBQ sauce. LPA also observed medications stored in one of the refrigerators that were unsecured from residents and stored with resident's food supply. LPA observed one resident's medication was mixed with hot chocolate and was unaware medications were being administered. LPA observed no physician's order and this was confirmed by the administrator and staff member (S1) who hid medications in hot chocolate. In discussions with S1 it was determined they did receive training in medications but did not take any exam to verify competency of medication administration per regulations. Additionally, LPA observed one staff member (S2) not associated to the facility. LPA confirmed the individual has a criminal record clearance but was to associated to the facility. Per the California Code of Regulations, Title 22, The following deficiencies are cited. An immediate civil penalty was also issued. Exit interview conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Feb 13, 2026

Criminal Record Clearance: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by LPA review of staff files and individual associations and observed R1 (see LIC 811 dated 2/12/26) did not have their criminal record clearance associated to the facility which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Administrator agrees to associate R1 by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(5)(D) · Plan of correction due date: Feb 13, 2026

Incidental Medical and Dental Care: Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement was not met as evidenced by LPA observations of staff members camouflaging medications in other substances as LPA observed open capsules of medications next to a cup of hot chocolate and residue of medications still visible in the cup. This was confirmed by S1 who administered the medications which poses an immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: All staff who provide medication administration to residents must receive updated training on medication administration and must pass an examination per the health and safety code demonstrating competency.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 13, 2026

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by LPA observations of a resident medication stored in a fridge without a lock box and accessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Administrator has ordered a lock box and will place medications in lock box immediately upon arrival.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.69(a)(5) · Plan of correction due date: Feb 13, 2026

Employees assisting residents with self-administration of medication; training requirements: To complete the training requirements set forth in this subdivision, each employee shall pass an examination that tests the employee's comprehension of, and competency in, the subjects listed in paragraph (3). This requirement was not met as evidenced by statements from S1 and file review for S1 that indicates S1 did not receive or pass a competency exam for medication administration which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: All staff who provide medication administration to residents must receive updated training on medication administration and must pass an examination per the health and safety code demonstrating competency.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Feb 13, 2026

Additional Personal Rights of Residents in Privately Operated Facilities: To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by LPA observations of staff member camouflaging medications in resident's hot chocolate without the resident's knowledge which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Administrator has agree to review all personal rights for residents with all staff members and provide the department staff signatures indicating they have all reviewed resident personal rights.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Feb 13, 2026

Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by the number of violations observed and the nature of the violations has demonstrated to the department the administrator has not demonstrated an knowledge of or ability to conform to the applicable laws, rules and regulations which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Administer has agreed to provide a statement that if offerred they would participate in TSP.

Type of visit: Case Management - Other

On 8/28/25 at 9:30am, Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo conducted an unannounced Case management inspection to deliver an immediate exclusion for a staff member associated to this facility. LPAs met with staff member Veniana Banuve to discuss the purpose of our visit. LPAs served the facility an immediate exclusion order for staff member R1 (See confidential names list, LIC 811 dated 8/28/25. LPAs obtained a current staff roster dated 2/28/25 to verify R1 is not currently on the schedule. LPAs observed there were three staff members listed on the schedule or present at the facility who did not have a criminal record clearance or associated to the facility. Per California code of Regulations, Title 22, the following deficiency is cited. An immediate civil penalty was issued during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 29, 2025

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility...Obtain a California clearance or a criminal record exemption as required by the Department...this requirement was no met as evidenced by LPAs review of staff records and roster which indicated three individuals on the schedule or present at the facility that do not have a criminal record clearance or associated to the facility which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Facility will ensure all staff members are fingerprint cleared and associated prior to being present at the facility. The facility will also submit a written plan of correction indicating the steps facility will take to ensure the violation does not reoccur

Type of visit: Required - 1 Year

On 04/18/2025 at 8:30am, Licensing Program Analyst (LPA) Pang Lee and Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Lee and Hughes met with Una Waqalala explained the purpose of the visit. The facility designated administrator was present in the facility. The current census is 12 with 3 facility staff. This facility is a single story building licensed to serve 15. LPA’s inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA's observed the facility to be free of odor, clean and in good repair. LPA's observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 107.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the kitchen and was last serviced on 03/03/2025. LPA's observed the facility has a has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was 72 degrees Fahrenheit. LPA's observed toxins located in the hallway closet and kept locked and inaccessible to residents. LPA's observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA's checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 6 out of 12 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA's requested resident and staff files for review. LPA's reviewed 7 out of 12 resident files and they were complete. LPA's reviewed 3 staff files, and it was complete. LPA's reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report (7) LIC 309 Administrator Organization As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Una Waqalala and a copy of these LIC 809 reports, LIC 809-C page, were provided to the facility.the state’s words, verbatim · CDSS document, Apr 18, 2025

Type of visit: Required - 1 Year

On 04/18/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee and Support staff (SS) Perla Mancillas arrived at the facility to conduct an unannounced annual inspection. LPA and SS met with direct care staff, Veniana Banuve and explained the purpose of the visit. Direct care staff called administrator, Una Wagalala. LPA and SS was informed that administrator is not able to join the visit and that direct care staff Veniana will assist with today’s visit. Administrator certificate # is 6056441740 and will expire on 07/08/2024. The current census is 13 with 3 facility staff. This facility is a single story building licensed to serve fifth teen (15) non-ambulatory residents and approved for 1 hospice residents. LPA and SS inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPA and SS observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA and SS observed residents’ room 101 was occupied by two facility staff which does not reflect the facility sketch and fire clearance. LPA and SS observed a folded roll out bed in residents’ room 102. It was learned that a staff sleeps on the roll out bed either in the activity room or the living room. It was also observed that the resident bathroom inside bedroom 102 is locked during the day and open for resident’s use at night due to the toilet leaking. LPA Lee did not observed any leak in the bathroom during today's visit. LPA and SS toured the kitchen and observed the pantry locked and not accessible to residents at this time. The facility had sufficient seven day non-perishable food supplies. It was observed that two day perishable food supplies were not sufficient for 13 residents in care. Hot water temperature was measured at 130.1 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 04/03/2024. LPA and SS observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA and SS observed toxins located in the hallway closet and kept locked and inaccessible to residents. LPA and SS observed sharp knives kept locked and inaccessible to residents. LPA and SS checked medication storage and found medication to be locked away and inaccessible to residents. LPA and SS reviewed and compared 4 medication administration record (MAR) along with residents’ medications. Records reviewed indicated that 1 out of 4 MAR log was inaccurate. Three out of 9 medication instruction did not have the current instruction information. The first aid kit was checked, and it was missing the thermometer. LPA Lee requested resident and staff files for review. LPA Lee reviewed 6 out of 13 resident files and 3 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 04/26/2024 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility staff Veniana Banuve.the state’s words, verbatim · CDSS document, Apr 18, 2024

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.