Sunnyside Senior Living

Type of visit: Required - 1 Year

Licesning Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct a annual inspection. LPA met with the administrative assistant (back up administrator) Krystal Calderon to explain the purpose of the visit. facility is a 56 bed facility with a 16 bedridden 40 non amb status. waiver is observed for 16 hospice folks. Physical inspection was conducted, water temp is outside of 105-120*F. there are posted signs at the taps. LPA gave guidance to recalibrate to the required range, rather than rely on the sign, particulary due to the cognitively impaired nature of the residents. 5 of 5 client files were reviewed for the admission agreeements, health screenings, needs and services plans, recent health assessements, emergency contact profile, and safeguarded property forms. Admission agreements are using the LIC template from 2005, there are some updates that are necessary, LPA asked for the administrator to review the regulations on the contents of admission agreements and develop a new admission agreement to be signed by the residents. client files otherwise present and up todate. 5 of 5 staff files were reviewed for the background checks, annual and continuing training, health ascreenings, qualifications and certification for first aid and CPR. in 2 of 5 the staff files reviewed, the annual training topic and time log appears to be missing topics for dementia and restriced care conditions present in the facility(o2 care). Annual training appears to be covered in a monthly training of around 1-2 hours, LPA gave guidance that annual training should cover 12 hours of the specific topics outlined in annual training regulation, plus 8 hours of dementia specific training, plus 4 hours each of restricted care related training. LPA notes there is at least folks with required oxygen present in the facility, making the mandatory annual training a minium of 24 hours(12+8+4). LPA gave guidance to take an inventory of the care needs of the folks for restricted care conditions and bring the annual trainings into compliance regarding ammounts and topics of training. staff files otherwise present and up to date. continued on c page admin docs were reviewed for the facility license, administrators certificate, 610 and evacuation controls. LPA couldn't locate a waiver for the facilities secured perimter status, gave guidance to either locate that by EoD 10/2/26 and submit it to the LPA(noel.wolfpetersen@dss.ca.gov) or submit a waiver request with a lic200 and a facility sketch detailing there is at least (Peoplex3) cubic feet of availible space that is more than 50ft of the buildings of the facility. 5 clients were interviewed, 5 staff were interviewed. no citations were issued a copy of the report was read and given to the administrator. exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 1, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to a health and saftey concern about the use of assistive devices. LPA met with the assistant administrator Krystal calderon to explain the purpose of the visit. LPA made an observation of the clients, 3 persons with an assistive devices were able to have proper access to and use of their assistive device. LPA spoke with 3 medtech staff, with the primary responsibility for perscribed device uses. Staff explained the content of their training on hernia belt training, just under the belly button, mornings and evenings on and off, meals are optionally off. no new medtechs were hired since the LPAs last visit. The LPA finds no concerns with the use of the assistive at this time. no citations were issued with this visit. a copy of the report was read and given to the administrator. exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 1, 2026

Allegation investigated: Staff did not follow the resident’s physician instructions

On 07/29/2026, Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced facility visit to deliver findings for complaint for the above allegations. LPA met with assistant adminstrator Crystal Calderon and explained the purpose of today's visit. Based on interviews and LPA observation R1 was recieving the care instruced by the physician it was observed over multiple visits to the facility. Therefore the allegation above is UNSUBSTANTIATED. A finding of unsubstaniated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the aegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 29, 2026 · control 27-AS-20260720125352

Type of visit: Case Management - Incident

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to a recent incident where a resident was able to consume another resident's medication. LPA met with administrative assistant Krystal calderon to explain the purpose of the visit. Met with staff relevant to the incident for an interview. At the time of the incident the facility did have a crush order on file for the med(dated 1/20/26), at the time of the incident the facility did not have a signed written consent form from responsible party about camofaluging the medication. Per the interview with the staff, the facility has other clients who are reciving crushed/camoflauched medication, LPA gave guidance that consents should be audited and updated as necessary. LPA was given a copy of the training that the facility gave as a part of thier own internal process for resolving the inccident. Per the care coordinator, one of the two medications has been switched to a liquid form. Citations were issued as apart of the visit. A Copy of the report was left the the administrator, LPA sent a copy of the best practices for Medication dispersal to the care coordinator. Exit interview was conductedthe state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 25, 2026

87465 Incidental Medical and Dental Care (a)(4) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not followed as evidenced by: record review/interview of a situation where under the implemented plan of the facility, R2 made use of unsupervised access to medication prescribed to R1, causing R1 to be short a dose of medication and R2 to take medication not prescribed to them. This poses an immediate risk to the health saftey and personal rights to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: No POC, the facility has retrained the staff on providing observation for the situation. new training matierals given to the lpa directly address the level supervision the staff should be providing the clients during med dispersal.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(5)(D) · Plan of correction due date: Mar 25, 2026

87465 Incidental Medical and Dental Care (a)(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement was not followed as evidenced by: Record review/interview that a client was receiving medication camoflaugeed by coffee without the residents written knowledge and consent facility did not have a signed knowledge and consent for Camoflauging medications at the time of the incident. This presents an immediate risk to the health safety and personal rights to residents in carethe state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: No POC, the facility has aquired consent from the relevant parties for this client, LPA gave guidance that an internal audit of all clients with crushed medication orders for a consent form should happen.

Type of visit: Case Management - Other

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. 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.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Required - 1 Year

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. 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. 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 facilitythe state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 11/26/2024. LPA met with Melissa Brichka, Administrator and explained the purpose of the visit. Staff Dawn Pero and Krystal Calderon assisted with today’s visit and were found to be associated to the facility. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a two story building licensed to service the elderly and those with dementia, age 60 and over or 56 non-ambulatory residents of which 16 may be bedridden. The first floor is approved for bedridden and a waiver was granted for hospice care for 16. LPA Campbell observed the facility to be free of odor, clean and in good repair. LPA Campbell observed 56 beds and 28 rooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. Fire extinguishers were last inspected on 01/02/2024. The temperature for the refrigerator was measured at 33 degrees Fahrenheit and the freezer was measured at -6 degrees Fahrenheit. LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. RCFE hot water temperatures are to be 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Hot water was measured at 130 degrees Fahrenheit in a resident's bathroom was found to be accompanied by a sign warning of hot water as required. Fire extinguishers, smoke and carbon monoxide detectors are in good repair as documented in fire drill logs. A fire drill log was reviewed by LPA Campbell. Per documentation, a monthly fire drill was conducted successfully and staff reviewed use of the fire extinguishers. Facility thermostat observed at 74 degrees Fahrenheit. LPA Campbell requested client and staff files for review. LPA reviewed 4 resident files and 4 staff files. Resident files were observed to be complete. Toxins were made inaccessible to clients in care. Toxins were stored in the laundry room and locked storage closets. The laundry room is locked when staff must leave it unattended. The following documents will be emailed to LPA Campbell (Renee.Campbell@dss.ca.gov) by 12/05/2024 by 12:00 PM : (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Nov 26, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

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. 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.the state’s words, verbatim · CDSS document, Sep 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 20, 2024

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: 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.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: 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

Type of visit: Case Management - Other

On 05/24/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced regarding closure of the facility under the former owner. LPA Campbell was met by Dawn Pero, Care Coordinator and Krystal Calderon, Administrative Assistant and explained the purpose of the visit. As LPA Campbell drove into the driveway of the facility, the new sign bearing the name Sunnyside Senior Living was observed. Upon entry, LPA observed clients eating breakfast and being assisted by staff. Residents were observed socializing and watching TV as well. During the visit, staff conducted a Bingo game for the residents. LPA Campbell confirmed that the current owner and facility Administrator for Sunnyside Senior Living was Nicole Ell as recorded in FAS. It was then found that the former facility owners (under the former name of St. Francis Assisted Care) had not completed their closure process. When asked, Dawn Pero stated she had the contact information for the former owners of St. Francis Assisted Care. LPA Campbell recorded the information and prepared a forfeiture letter to be mailed to the former owners via certified mail from the regional office. Form 9104 was also prepared so that closure could be processed. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 24, 2024

Type of visit: Prelicensing

On 11/21/2023, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a Pre-Licensing Visit. LPA met with applicant Nicole Ell, Administrator and Albert Ell, Vice President and explained the purpose of the visit. The purpose of this Pre-Licensing Visit is due to a change of ownership. Current census is 39 residents at this time. The facility has a fire clearance for 40 non-ambulatory and 16 bedridden residents. LPA observed the secure file room where staff and resident files are kept locked in a file cabinet. A tour of the facility was conducted. It was observed that a new resident in a shared bedroom did not have a chest of drawers yet but her family would be bringing one for her. The facility stated that they will provide a bed, night stand, chair, lighting and drawers if the resident is not able to provide it for themselves. A tour of the kitchen was conducted. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care. The refrigerator had a temperature of 39 degrees Fahrenheit and the freezer -4.6 degree Fahrenheit. A tour of the pantry was conducted where the facility holds extra non-perishable food supplies. The facility regularly rotates out emergency food supplies to maintain freshness. LPA observed a locked centralized stored medication cabinet located in the Med Tech office near the front of the building. The MAR's log book and the locked narcotics box was observed as well. A First Aid Kit was present and contained all of the required components. A fire extinguisher was located in the living room and was last serviced on 01/26/2023. Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time. An additional emergency food supply was observed in an outside shed. A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents . Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited during visit. During today's visit Component III was done with Nicole Ell. An exit interview was conducted with the Administrator and a report left.the state’s words, verbatim · CDSS document, Nov 21, 2023