092700093-7-17-2024-59-AS-LMUZ-D7EPAH-20240722110844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700093
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:18:52 PM

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
04/02/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240402123206

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: 12	DATE:	07/17/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Caregiver Rosa Hernandez		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff yelled at resident

INVESTIGATION FINDINGS:

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On 7/17/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Rosa Hernandez.During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.
The results of the investigation are as follows:
The department conducted interviews with staff and residents and reviewed records to investigate the allegation. Interviews indicated that staff do did speak a little loudly with residents that have trouble hearing. It is not possible to say with certainty what a staff or resident may perceive as yelling, or what a particular tone of voice may sound like to someone else. Therefore, the department is not able to conclude if staff was in fact intending to yell or did yell at a resident; or if staff’s voice was perceived as yelling. Therefore, the allegation is 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 conducted and copy of this report was left at 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: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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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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
04/02/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240402123206

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: 12	DATE:	07/17/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Caregiver Rosa Hernandez		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Staff left resident in soiled diaper for an extended amount of time
Staff lost resident's hearing aide and won't reimburse the authorized representative
Staff over medicated the resident

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: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240402123206

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: 07/17/2024

NARRATIVE

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Staff left resident in soiled diaper for an extended amount of time - UNFOUNDED
Department conducted record review, staff, and resident interviews to investigate this allegation. Staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours, or as needed. Resident interviews reflected that their care needs were met by staff and there were no issues to address, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff lost resident's hearing aide and won't reimburse the authorized representative - UNFOUNDED
Through the course of the investigation process, CCL conducted interviews, toured the facility, and reviewed records regarding the allegation above. During the investigation it was determined that R1 always misplaced R1’s hearing aids. Facility was able to locate one hearing aid and the other was reimbursed to the family. Department received confirmation of the reimbursements made to R1’s representative. Statements by staff and other residents failed to demonstrate a lack of care for residents’ personal property. Therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff over medicated the resident - UNFOUNDED
Through the course of the investigation process, CCL conducted interviews, toured the facility, and reviewed records regarding the allegation above. During the investigation, the department was provided copies of the medical records for R1. The medical records included the current medication and dosage instructions. A review of the MARS report was conducted. The Department found that all medications for R1 were given per physician’s order. The Department found no supporting evidence that would indicate that the resident was over medicated. Therefore, the above 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 conducted and copy of this report was left at the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC9099 (FAS) - (06/04)

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