092700093-10-30-2023-59-AS-LMUZ-CXCTQS-20231107135625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700093
Report Date: 10/30/2023
Date Signed: 10/30/2023 10:07:04 AM

Unfounded

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
09/19/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230919102105

FACILITY NAME:	SUNSHINE MANOR		FACILITY NUMBER:	092700093
ADMINISTRATOR:	MOTUOMANONO SOKIMI		FACILITY TYPE:	740
ADDRESS:	3112 WASHINGTON STREET		TELEPHONE:	(530) 622-3940
CITY:	PLACERVILLE	STATE: CA	ZIP CODE:	95667
CAPACITY:	14	CENSUS: 11	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Motu Sokimi		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff admitted resident with prohibited health condition
Staff did not assist resident with meeting medical needs

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 59-AS-20230919102105

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 MANOR	FACILITY NUMBER: 092700093
	VISIT DATE: 10/30/2023

NARRATIVE

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Staff admitted resident with prohibited health condition.
Staff did not assist resident with meeting medical needs.
Department conducted interviews and record review to investigate these allegations. Based on that, the department was unable to find any evidence that the facility was retaining any residents with a prohibited health condition or that staff was not assisting residents with medical needs beyond the scope of this license. Based on interviews and records reviewed all residents that require nursing care were on hospice and those that were not on hospice did not have any prohibited health conditions. All residents were assisted with all their care needs based on their needs and service plan; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
09/19/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230919102105

FACILITY NAME:	SUNSHINE MANOR		FACILITY NUMBER:	092700093
ADMINISTRATOR:	MOTUOMANONO SOKIMI		FACILITY TYPE:	740
ADDRESS:	3112 WASHINGTON STREET		TELEPHONE:	(530) 622-3940
CITY:	PLACERVILLE	STATE: CA	ZIP CODE:	95667
CAPACITY:	14	CENSUS: 11	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Motu Sokimi		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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On 10/30/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Motu Sokimi.
During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows:

Staff did not administer resident's medication as prescribed. UNSUBSTANTIATED
Based on documents obtained and statements received, the department determined that there was insufficient evidence that any resident’s medication was not administered as prescribed. Documents obtained showed that all current medications were administered and logged correctly. Based upon the information obtained during investigation, the above allegation found to be Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administroator and a copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3