342701147-4-24-2023-27-AS-KHOS-CRGN4U-20230503100831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701147
Report Date: 04/24/2023
Date Signed: 04/24/2023 03:34:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230130111512

FACILITY NAME:	SUNNY SIDE CARE HOME		FACILITY NUMBER:	342701147
ADMINISTRATOR:	MASSAQUOI, MOHAMED		FACILITY TYPE:	740
ADDRESS:	8436 KEUSMAN ST.		TELEPHONE:	(916) 897-8347
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 3	DATE:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Niomi Massaquoi		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff are limiting resident's access to their family member.
Facility staff are withholding resident's medication from them.
Facility staff does not provide resident socialization activities.
Facility staff are not adequately feeding resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced to deliver findings on this complaint investigation. LPAs Moleski and Lund met with Niomi Massaquoi and explained the purpose of the visit.

This investigation consisted of interviews with Mohamed Massaquoi, interviews with S1, S2, R3, and R4, review of resident records, review of facility files, and observation of the facility’s food supplies.

LPA Moleski observed on two separate occasions adequate supplies of food on the facility premises, and reviewed meal menus with adequate meals planned for residents. During an interview, R3 did not express significant concerns regarding food at the facility.

[Continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230130111512

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 342701147
	VISIT DATE: 04/24/2023

NARRATIVE

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During interviews, S1 and S2 said visitors visit the facility whenever they like, but usually call ahead first. In interviews, Mohamed Massaquoi said visitors are encouraged to call ahead, but are not required to. Mohamed Massaquoi also said he has attempted to make accommodations around family members’ schedules. R3 did not express any concerns regarding visitation.

LPA Moleski reviewed MARs for R4 and observed three missed doses of a single medication in January 2023. The MARs indicated the doses were not given because there was no refill available. Mohamed Massaquoi said R4’s responsible party had not authorized the refill on time. S1 and S2 did not indicate any issue with getting refills at the facility. R3 did not express any concerns regarding medications.

LPA Moleski reviewed planned activity calendars for the facility. During an interview, S1 said they tried to engage residents in activities, but residents were either uninterested or could not engage due to advanced dementia. R3 did not express concerns regarding the activities available to residents.

The department has determined the following as it relates to the allegations that facility staff are limiting resident’s access to their family member, that facility staff are withholding resident's medication from them, that facility staff does not provide resident socialization activities, and that facility staff are not adequately feeding resident:

The above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Niomi Massaquoi.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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