502701283-10-2-2025-27-AS-RCAL-DM3UX5-20251002155745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701283
Report Date: 10/02/2025
Date Signed: 10/02/2025 03:58:17 PM

Document Has Been Signed on 10/02/2025 03:58 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 INC		FACILITY NUMBER:	502701283
ADMINISTRATOR/ DIRECTOR:	MELISSA BRICHKA		FACILITY TYPE:	740
ADDRESS:	120 2OTH CENTURY BLVD		TELEPHONE:	(209) 614-5171
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95380
CAPACITY: 56		CENSUS: 47	DATE:	10/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Krystal Calderon, Administrative Assistant		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 10/02/2025, Licensing Program Analyst (LPA) Renee Campbelll arrived unannounced to conduct an annual inspection with Stephenie Doub, Regional Manager. Krystal Calderon, Administrative Assistant assisted with the visit. LPA Campbell observed residents eating breakfast. The contact information for the Long-Term Care Ombudsman was displayed in the entrance for residents and visitors. There was also a See Something Say Something poster available to call in complaints. Throughout the day, LPA Campbell overheard residents using the signal system to call for a caregiver. Later during the visit, LPA Campbell observed two residents working on a puzzle together and a religious service was done in the common area with a priest and residents as parishioners. Upstairs, residents were observed eating lunch in the dining room. Staff were observed serving the meals and assisting where needed. The community is licensed to serve residents age 60 and over who are non-ambulatory of which 16 of them may be bedridden. Only the first floor is approved for bedridden residents and the community has a waiver granted for 16 hospice residents. A tour was conducted with Dawn Pero, Care Coordinator in the Med room, resident rooms, kitchen and common areas. LPA Campbell conducted a medication audit using randomly selected residents and found that the residents medication matched their name, rx, number, name of medication and the dosage prescribed. The first aid kit was inspected and included tweezers, scissors, thermometer and first aid manual along with bandages.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

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

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/02/2025

NARRATIVE

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LPA Campbell observed three resident rooms and found that the appropriate furnishings were present. However one room (#101) did not have a lamp available for residents outside of the overhead lights. LPA Campbell reminded the Care Coordinator that each resident is to have a lamp on the night stand for their personal use. Lamps were found in the other two rooms that were inspected. The water temperature in the three residents rooms inspected were all found to be over 120 degrees Fahrenheit. However all bathrooms were found to have signage warning of hot water and all residents were able to discern if the water was too hot. The thermostat was set at 75 degrees F

During a tour of the community kitchen, LPA Campbell observed stoves with a fire supression system that was last inspected on 06/19/2025. There was a class K fire extinguisher for cooking oil and fat fires and a Class A fire extinguisher. Both fire extinguishers were last inspected on 12/18/2024 and were fully charged. When LPA Campbell observed the freezer and refrigerator, the temperature displayed was within regulations. The refrigerator was 35 degrees Fahrenheit (F) and the freezer was -5 degrees Fahrenheit. There were enough perishable foods to last the community 2 days and enough non-perishable items in the pantry to last 7 days. A temperature log was observed to be kept on the front of freezer and refrigerator. No insects, spiders or spider webs were observed in the community.
LPA Campbell also observed the emergency food supply stored in an outside shed.

LPA Campbell reviewed the fire drill log for the community. Staff conducted quarterly drills once per quarter and recorded the date, time, number of residents and staff who participated and the scenario practiced. The administrator reviewed and signed off on each drill.

After a review of the emergency and disaster plan, RM Stephen Doub consulted with staff regarding feasability. The community will update and expand the Emergency and Disaster Plan and provide the new plan to LPA Campbell by 10/10/2025.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC809 (FAS) - (06/04)

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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: 10/02/2025

NARRATIVE

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LPA Campbell compared the staff roster to the online Guardian report. One staff was not found in the Guardian but was added during the visit. LPA Campbell conducted 10 file reviews for residents and 5 file reviews for staff. All files were found to be complete.

The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 10/09/2025 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(4) LIC 610 Emergency Disaster Plan
Updated Insurance Certificate
Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC809 (FAS) - (06/04)

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