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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701283
Report Date: 10/23/2025
Date Signed: 10/23/2025 01:30:12 PM

Document Has Been Signed on 10/23/2025 01:30 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/
DIRECTOR:		MELISSA BRICHKAFACILITY TYPE:
740
ADDRESS:120 2OTH CENTURY BLVDTELEPHONE:
(209) 614-5171
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 56CENSUS: 46DATE:
10/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Dawn Pero, Care Coordinator TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 10/22/2025, Licensing Program Analyst (LPA) Renee Campbell received an incident report regarding Resident 1's (R1's) back brace and a missing bolt. Per the report, a friend of the responsible party came and provided a temporary solution with a replacement bolt. LPA Campbell contacted the responsible party (P1) and interviewed staff at the facility on 10/23/2025.

LPA Campbell contacted the responsible party (P1) on 10/23/2025 regarding the incident. Per P1, the facility had not initially made sure that R1 was using the back brace. When staff notified P1 that a bolt had gone missing, a family friend came to the facility and provided a temporary replacement bolt. The combination of the missing bolt and because staff not hot initially provided support for usage of the back brace, P1 concluded that facility staff were not taking responsibility for R1 using the back brace correctly and they were not keeping track of the brace to avoid losing parts.

When staff was interviewed on 10/23/2025, S1 stated that the facility had not known that staff needed to support R1's use of the back brace because they had not received doctor's orders regarding the back brace. Instead, S1 stated that P1 had "just shown up with it." and given it to staff. S1 then requested that P1 obtain doctor's orders so that staff could be properly trained and informed on how to properly assist R1 in using the brace. Once received staff then assisted R1 in putting on the brace in the mornings and taking it off in the evening. S1 had notified P1 on 10/22/2025 that staff noticed the bolt was missing from R1's back brace when they were assisting R1 with putting the brace on that morning.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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: 10/23/2025
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To avoid further miscommunication, the facility has taken steps to educate staff and document any issues that may arise when assisting with the back brace. Training has been conducted with 19 staff on the parts of the back brace and how to take it on and off (10/01, 10/18, 10/25) In the future, staff will scan for any missing parts or other issues when assisting R1 into or out of the back brace and document any changes in R1's notes.

P1 will also be notified of additional resources in regards to regulations for Residential Care Facilities for the Elderly (RCFE) to familiarize themselves with procedures and what the facilities can and cannot do.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of the report was provided to Dawn Pero, Care Coordinator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
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