045003003-8-27-2024-59-AS-KHOS-D92M54-20240912091744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045003003
Report Date: 08/27/2024
Date Signed: 08/27/2024 09:18:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240723135631

FACILITY NAME:	SUNSHINE ASSISTED LIVING- THE COTTAGE		FACILITY NUMBER:	045003003
ADMINISTRATOR:	BAKER, JENNAH		FACILITY TYPE:	740
ADDRESS:	1468 SUN MANOR		TELEPHONE:	(530) 887-3363
CITY:	PARADISE	STATE: CA	ZIP CODE:	95969
CAPACITY:	17	CENSUS: 22	DATE:	08/27/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Lisa Fennel		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff do not provide adequate food service to residents.

INVESTIGATION FINDINGS:

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On 08/27/2024 Licensing Program Analyst Boyles made an unannounced visit to the facility and met with administrator. The purpose of this visit was to deliver the results of a complaint investigation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.
An exit interview was conducted. A copy of the report was provided to administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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 59-AS-20240723135631

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUNSHINE ASSISTED LIVING- THE COTTAGE	FACILITY NUMBER: 045003003
	VISIT DATE: 08/27/2024

NARRATIVE

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LPA investigated, “Staff do not provide adequate food services to residents”. LPA interviewed the resident who reported that they receive three meals a day and snacks when requested. LPA reviewed the residents needs and services plan, 602 and IPP which indicate that the resident is a “picky eater” but has no documented dietary restrictions. LPA interviewed the administrator who reported that the resident does not have a diagnosis which would require a specialized diet. LPA interviewed a family member to the resident, who reported that when the resident moved into the facility that the facility would accommodate the residents desire to have alternative to the menu but has since changed the process for facilitating substitutions for meal time.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC9099 (FAS) - (06/04)

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