092700093-10-30-2023-59-AS-LMUZ-CXCTQ8-20231107135531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700093
Report Date: 10/30/2023
Date Signed: 10/30/2023 10:09:56 AM

Substantiated

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-20230919083923

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:	09:53 AM
MET WITH:	Administrator Motu Sokimi		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Facility staff are sleeping in resident's bedroom

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:
Facility staff are sleeping in resident's bedroom. - SUBSTANTIATED
Department conducted interviews, records were reviewed and facility observation to investigate this complaint allegation. As a result of the investigation: department finds that a former staff member did sleep in a resident's room. That staff member quit their position since the incident happened. As a result of this investigation, department finds the allegation(s) to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation(s) s valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

Exit interview with administrator. Appeals rights provided. Copy of the report provided to facility.

Substantiated

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)

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Control Number 59-AS-20230919083923

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/31/2023 Section Cited CCR 87468.2(a)(1)	1 2 3 4 5 6 7	87468.2(a)(1) Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.2, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1)To have a reasonable level of personal privacy in accommodations ... This requirement was not evidence by:	1 2 3 4 5 6 7	Licensee will ensure that no staff can sleep in any resident’s room(s) at any time and agrees to submit a statement of understanding of this regulation to CCL by the POC date- 10/31/23.
	8 9 10 11 12 13 14	Interviews indicated that facility staff did intrude into a resident’s room to sleep, invading the resident’s privacy. This is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

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