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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701147
Report Date: 03/03/2025
Date Signed: 03/03/2025 02:09:48 PM

Document Has Been Signed on 03/03/2025 02:09 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: 5DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mohamed MassaquoiTIME VISIT/
INSPECTION COMPLETED:
02:20 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.

Upon arrival, LPA Moleski observed two staff members present (S1-S2). S1 said they had been working at this facility for one week. Massaquoi said that S1's start date was Wednesday, 2/26/25. LPA Moleski reviewed Guardian records and observed that S1 was associated to this facility as of 3/1/25, but was not cleared prior to that date. S2 said that they had been working at this facility for three years on an on-call basis. LPA Moleski reviewed Guardian records and observed that S2 was not associated to this facility.

LPA Moleski reviewed five resident files (R1-R5) and one staff file (S2). S1 did not have a personnel file. Massaquoi said he was still working on completing S1's file. Massaquoi said that S2's personnel file was located at another facility. Massaquoi left and returned with S2's file, which was missing several required elements.

R1 moved in as of 3/2/25. R1 did not have a medical assessment [LIC 602] on file prior to admission. R1's pre-placement appraisal was partially completed, and indicated that R1 is non-ambulatory, but did not include an appraisal of R1's health history, mental condition, or any social factors. The partially completed pre-placement appraisal was not signed by R1 and/or R1's responsible parties, but was signed by Massaquoi. R2's pre-placement appraisal was signed by all parties, but was signed on 2/27/25, one day after their admission date of 2/26/25. R4, who was admitted on 2/18/25, did not have any pre-placement appraisal on file. Additionally, R4's LIC 602 did not include any tuberculosis test results or the results of a chest x-ray.

LPA Moleski reviewed four residents' LIC 602s (R2-R5). As previously mentioned, R1 did not have an LIC 602 on file. R2-R5 all had LIC 602s which identified them as non-ambulatory. [continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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 7
Document Has Been Signed on 03/03/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/03/2025 at 09:55 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)(A)
"Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs ... The appraisal shall document, at a minimum: ... An evaluation of the prospective resident's functional capabilities, mental condition, and social factors..."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, more than one resident's preplacement appraisals were not completed or signed by the resident and/or their responsible party prior to admission, which poses a potential health, safety, and/or personal rights risk.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with the residents' completed and signed appraisal and needs and services plan by POC due date.
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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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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: 03/03/2025
NARRATIVE
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R1's pre-placement appraisal, which was signed by Massaquoi, identified R1 as non-ambulatory. LPA Moleski also observed R1 using a wheelchair during this visit. This facility has a fire clearance which permits admission of no more than four non-ambulatory residents. None of these non-ambulatory residents are permitted to reside within bedroom #3, according to this facility's fire clearance.

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 76 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 131 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees.

While touring the facility, LPA Moleski observed multiple cleaning solutions left in unlocked cabinets in resident bathrooms, including cleaners which contained bleach. LPA Moleski asked Massaquoi for the residents' centrally stored medication records. Massaquoi was not able to produce centrally stored medication records which included start dates or dates that prescription orders were filled for any resident.

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 cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S2) and one resident (R4).

This facility is hereby cited per 22 CCR Sections 87202(a), 87355(e)(3), 87457(c)(1)(A), 87458(a), 87458(c)(1), 87412(a), 87465(a)(6), 87303(e)(2), 87309(a)(1). An immediate civil penalty in the amount of $500 is hereby assessed due to a violation of fire clearance. Civil penalties for violations of criminal record clearance are assessed in the amounts of $100 per day worked without criminal record clearance/association per staff member. Civil penalties are assessed for a maximum of five days worked by S2 and three days worked by S1 [2/26/25 - 2/28/25] prior to clearance/association. Combined, all civil penalties assessed during this visit total $1,300.

An exit interview was held with Massaquoi. Appeal rights and a copy of this report was left with Massaquoi.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/03/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/03/2025 at 01:09 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, this facility admitted a greater number of non-ambulatory residents than permitted by fire clearance, which poses an immediate health, safety, and/or personal rights risk.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee agrees to send LPA Moleski a written plan identifying which steps they plan to take to address this deficiency, either requesting an updated fire clearance or evicting a resident, by POC due date. vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperature was not maintained within the required range, which poses an immediate health, safety, and/or personal rights risk,
POC Due Date: 03/04/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a photograph of an updated temperature reading within the required range 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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/03/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/03/2025 at 01:09 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) 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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions were not kept in locked storage, as required, which poses an immediate health, safety, and/or personal rights risk.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a plan for staff training regarding chemical storage by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, two staff members worked without having criminal record clearance/association, which poses an immediate health, safety, and/or personal rights risk.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee agrees to associate S2 and to provide LPA Moleski with a written statement acknowledging all criminal record clearance requirements 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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/03/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/03/2025 at 01:09 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, two staff members did not have completed staff files on the premises upon arrival, which poses a potential health, safety, and/or personal rights risk.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with copies of both staff members' personnel files by POC due date. vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, complete centrally stored medication records were not maintained on each resident, which poses a potential health, safety, and/or personal rights risk.
POC Due Date: 03/14/2025
Plan of Correction
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2
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4
Licensee agrees to provide LPA Moleski with completed centrally stored medication records for all residents 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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/03/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/03/2025 at 01:09 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, a resident did not have a medical assessment on file prior to admission to this facility, which poses a potential health, safety, and/or personal rights risk.
POC Due Date: 03/14/2025
Plan of Correction
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2
3
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Licensee agrees to provide LPA Moleski with the outstanding LIC 602 by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, a resident did not receive tuberculosis test results during their medical assessment, nor did they receive results of a chest x-ray, which poses a potential health, safety, and/or personal rights risk.
POC Due Date: 03/14/2025
Plan of Correction
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2
3
4
Licensee agrees to send LPA Moleski documentation of either a negative TB test or results from a chest x-ray indicating no evidence of active, communicable tuberculosis 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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
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