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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701147
Report Date: 03/21/2023
Date Signed: 03/21/2023 02:50:55 PM

Document Has Been Signed on 03/21/2023 02:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNNY SIDE CARE HOMEFACILITY NUMBER:
342701147
ADMINISTRATOR:MASSAQUOI, MOHAMEDFACILITY TYPE:
740
ADDRESS:8436 KEUSMAN ST.TELEPHONE:
(916) 897-8347
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 3DATE:
03/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sween Alicia MorrisonTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Jamie Ivey Canady arrived at the facility unannounced. LPA met with caregiver Sween Morrison. Sween contacted the administrator via phone. LPA spoke with administrator MASSAQUOI, MOHAMED and explained the reason for the visit. Mohamed gave Sween permission to sign for today's visit and gave LPA POC via phone.

Administrator certificate Number: 6049923740 Expires - 7/17/2023

Reference facility visit dated 3/07/2023, LPAs Ivey Canady and Valerio and LPM Richardson observed the facility had been changed. The front room has been divided and enclosed and made into two separate rooms. According to administrator, there has not been a fire clearance for the change and Community Care Licensing (CCL) has not been notified with a clearance and updated facility sketch.

Based on Title 22 regulations, licensee cited. Exit interview held, report given via email due to printer malfunction,

Continued on 809-D

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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Document Has Been Signed on 03/21/2023 02:50 PM - It Cannot Be Edited


Created By: Jamie Ivey-Canady On 03/21/2023 at 09:34 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY SIDE CARE HOME
FACILITY NUMBER: 342701147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2023
Section Cited
CCR
87203

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This was not met as evidenced by:
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Licensee stated there will be an appointment scheduled with the Sacraemnto County Fire Marshall to obtain an updated cleared facility sketch and send a copy via email to facility LPA No Later Than (NLT) 04/04/2023.
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Licensee did not ensure the Fire Marshall cleared the facility changes prior to making changes to the facility. LPAs observed the facility has changed the facility by dividing one room into two. Community Care Licensing (CCL) has not received an updated cleared facility sketch. This poses an potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023


LIC809 (FAS) - (06/04)
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