<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701283
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:17:34 PM


Document Has Been Signed on 09/11/2024 03:17 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUNNYSIDE SENIOR LIVING INCFACILITY NUMBER:
502701283
ADMINISTRATOR:ELL, NICOLEFACILITY TYPE:
740
ADDRESS:120 2OTH CENTURY BLVDTELEPHONE:
(209) 614-5171
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY:56CENSUS: 44DATE:
09/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dawn Pero, Care CoordinatorTIME COMPLETED:
03:45 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
On 09/11/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility at approximately 9:30 am regarding an eviction request. LPA Campbell met with Administrative Assistant Krystal Calderon and Care Coordinator, Dawn Pero and explained the purpose of the visit. LPA Campbell also spoke with Administrator Nicole Ell by phone.

On 09/06/24, Administrator/Licensee Nicole Ell submitted a copy of an eviction notice that would be provided to a resident (R1). After review, it was found that the facility needed to increase documentation of their search for an alternative placement (what places have been visited? their cost? can R1 afford it?). The facility should also provide detailed documentation of their attempts to help R1 find a new living situation (the name of the facilities, dates of visits to new facilities, details of refusals by R1 to visit a new facility.) In an attempt to help R1 resolve his behavioral issues, the facility will need to document contacts with R1’s psychiatrist using R1’s Medical Release Confirmation form. The facility must also write a plan if R1 cannot find a place to his liking within the 30 day timeframe.

LPA Campbell consulted with both staff and the Administrator and explained that the purpose of the eviction procedure was to make sure client needs are met by ensuring an appropriate facility is found. LPA Campbell spoke to Administrator Nicole Ell to clarify the Reporting Requirements and the importance of being familiar with Title 22 Regulations.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNNYSIDE SENIOR LIVING INC
FACILITY NUMBER: 502701283
VISIT DATE: 09/11/2024
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
26
27
28
29
30
31
32
Per Title 22, written reports or Unusual Incident Reports (UIR) are to be submitted to licensing within 7 days. On 09/06/24, the facility emailed faxes (for incidents that occurred on 08/22/24 and 08/23/24) that had not been faxed until more than 7 days after the incidents. No further attempts were made to send the reports to licensing.

When appraisals were discussed with staff. S1 and S2 stated that S2 does an pre-admission appraisal, S1 creates a Care Plan and S2 does a re-appraisal as needed. Both staff stated they were not trained medical or behavioral specialist. Per S2, no medical personnel are involved in reappraisals or assessment for mental health issues when admitted to the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. 


An exit interview was conducted, and copies of the report and appeal rights left. 
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/11/2024 03:17 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SUNNYSIDE SENIOR LIVING INC
FACILITY NUMBER: 502701283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
87211 (a)Each licensee shall furnish to the licensing agency ... (1) A written report ... submitted to the licensing agency ...within seven days of the occurrence of any ... events. This requirement was not met based on:
1
2
3
4
5
6
7
The administrator will present a signed declaration of understanding for the Reporting Requirements regulation found in 87211(a) by POC date. The licensee will ensure that incident reports will be submitted within 7 business daysl
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not insure all incident reports were submitted to licensing within seven days which poses a potential Health, Safety or Personal Rights risk to persons 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3