092700093-6-18-2025-59-AS-LMUZ-DHWNYH-20250623105247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700093
Report Date: 06/18/2025
Date Signed: 06/18/2025 12:35:42 PM

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
04/24/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20250424113440

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:	06/18/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Assistant Administrator Vicki Boe		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility bedroom outlets are in disrepair
Licensee does not ensure residents room have adequate lighting

INVESTIGATION FINDINGS:

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On June 18, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Assistant Administrator Vicki Boe.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

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: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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-20250424113440

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: 06/18/2025

NARRATIVE

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Facility bedroom outlets are in disrepair
Based on observation and statements reviewed, the department determined that there was insufficient evidence that the facility’s bedroom outlets are in despair. Department observation did not see any outlets broken or not properly maintained. Based upon the information obtained during investigation, 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.

Licensee does not ensure residents room have adequate lighting
Based on observation and statements reviewed, the department determined that there was insufficient evidence that the Licensee did not ensure residents room have adequate lighting. Facility did have an extra lamp for resident, however, due to resident’s roommate requesting a dimmer atmosphere, it was not used. The family of both residents were aware; therefore, no regulation has been violated at this time. 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. Report left with facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

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