342701147-3-7-2023-27-AS-JICY-CPQ5CU-20230307185051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701147
Report Date: 03/07/2023
Date Signed: 03/07/2023 06:51:35 PM

Document Has Been Signed on 03/07/2023 06:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SUNNY SIDE CARE HOME		FACILITY NUMBER:	342701147
ADMINISTRATOR:	MASSAQUOI, MOHAMED		FACILITY TYPE:	740
ADDRESS:	8436 KEUSMAN ST.		TELEPHONE:	(916) 897-8347
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 3	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	MASSAQUOI, MOHAMED		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Jamie Ivey Canady and Christina Valerio, Licensing Program Manager (LPM) Stephen Richardson arrived at the facility unannounced and explained the reason for today's visit. LPAs and LPM met with administrator MASSAQUOI, MOHAMED. LPAs and LPM toured the facility with caregiver Alicia Sween. Administrator certificate Number: 6049923740 Expires - 7/17/2023 LPA toured and inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area for the ability to prepare food. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 74F which is within the required range of 68-85F. The hot water temperature was measured at 110F which is within the required range of 105-120F. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke detectors and pull alarm system. Facility has central heating and air. Per the California Code of Regulations, Title 22, violations were observed during this visit. Exit interview held, copy of report sent to administrator via email due to printer malfuction.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

Document Has Been Signed on 03/07/2023 06:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY SIDE CARE HOME	FACILITY NUMBER: 342701147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review and observation, the licensee did not comply with the section cited above in which 2 out of 3 personnel files did not have Health Screening reports and TB test in accordance to Title 22, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2023
	Plan of Correction
1 2 3 4	Licensee will email LPA email confirmation of scheduled Health Screening and TB Test appointment date by COB 3/8/2023.

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2