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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701147
Report Date: 04/16/2024
Date Signed: 04/16/2024 12:14:33 PM

Document Has Been Signed on 04/16/2024 12:14 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:SUNNY SIDE CARE HOMEFACILITY NUMBER:
342701147
ADMINISTRATOR/
DIRECTOR:		MASSAQUOI, MOHAMEDFACILITY TYPE:
740
ADDRESS:8436 KEUSMAN ST.TELEPHONE:
(916) 897-8347
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 2DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mohamed MassaquoiTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Mohamed Massaquoi and explained the purpose of the visit.

LPA Moleski reviewed two resident files (R1-R2) and three staff files (S1-S3). R1 has a colostomy, according to R1's LIC 602s. LPA Moleski did not observe a current record of care in R1's file for the colostomy, or documentation from a physician that the colostomy wound was healed, or documentation from a physician that R1 was able to manage colostomy care needs independently. Massaquoi said that R1 manages care of the colostomy independently, and said that the wound is healed. Massaquoi said there was no current record of care or other current physician's documentation regarding R1's colostomy.

LPA Moleski reviewed medication administration records (MARs) for R1 and R2 for the month of April 2024. LPA Moleski observed that signatures in these MARs were complete through to April 9, 2024. Signatures for medication administrations between April 10 and April 16, 2024, were absent. Massaquoi said that S1 had been providing medication assistance during this time period, but did not sign because S1 has not been trained on medication administration. LPA Moleski reviewed S1's file and observed no training documentation present.

LPA Moleski toured the facility with Massaquoi and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 120 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 04/16/2024 12:14 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/16/2024 at 10:23 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNNY SIDE CARE HOME
FACILITY NUMBER: 342701147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87611(b)(1-3)
"(b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:

(1) Documentation from the physician of the following:

(A) Stability of the medical condition(s);

(B) Medical condition(s) which require incidental medical services;

(C) Method of intervention;

(D) Resident's ability to perform the procedure; and

(E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance.

(2) The names, address and telephone number of vendors, if any, and all appropriately skilled professionals providing services.

(3) Emergency contacts."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not ensure R1 had a current record of care on file as described above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee agrees to arrange a medical appointment for R1 and will send LPA Moleski confirmation of an appointment as soon as one is made.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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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: SUNNY SIDE CARE HOME
FACILITY NUMBER: 342701147
VISIT DATE: 04/16/2024
NARRATIVE
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LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked drawer for the storage of medication. LPA Moleski observed a locked drawer for the storage of knives. A cabinet below the facility's kitchen sink was unlocked. The lock was broken and not functional.

LPA Moleski interviewed one staff member (S1) and two residents (R1-R2).

This facility is being cited per 22 CCR Sections 87411(d)(4), 87611(b)(1-3) and 87309(a). An exit interview was held with Massaquoi. Appeal rights and a copy of this report were left with Massaquoi.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/16/2024 12:14 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/16/2024 at 12:03 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNNY SIDE CARE HOME
FACILITY NUMBER: 342701147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure cleaners were locked up, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee agrees to fix the lock on the cabinet by POC due date. Licensee agrees to send LPA Moleski a photograph of the replacement by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not ensure S1 was trained on medication administration prior to assisting with medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee agrees to conduct staff training and to send LPA Moleski a sign-in sheet by POC due date.
vincent.moleski@dss.ca.gov
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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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