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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701147
Report Date: 04/19/2023
Date Signed: 04/19/2023 11:44:21 AM

Document Has Been Signed on 04/19/2023 11:44 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 AC/SC, 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:
04/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Staff - Trudion HarriotTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived at this facility unannounced to follow-up on a complaint investigation. While at the facility, LPAs Moleski and Lund observed overgrown weeds in the facility's front and back yards, a sagging fence, and a broken gate. LPA Moleski spoke with Mohamed Massaquoi over the phone and explained the purpose of the visit. Massaquoi said staff were able to sign for in his absence.

This facility is being cited per 22 CCR 87303(a). Appeal rights and a copy of this report were left with staff member Trudion Harriot.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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 04/19/2023 11:44 AM - It Cannot Be Edited


Created By: Vincent Moleski On 04/19/2023 at 11:28 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: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
CCR
87303(a)

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"The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors." This was not met as evidenced by LPA observation of the front yard, back yard, untrimmed grass, broken gate and sagging fence.
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Licensee will cut grass and fix fence and gate, or have a work order to fix the fence and gate.

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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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023


LIC809 (FAS) - (06/04)
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