315920051-7-16-2026-59-AS-TORZ-DWLSAA-20260803134201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315920051
Report Date: 07/16/2026
Date Signed: 07/16/2026 01:53:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2026 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20260518103141

FACILITY NAME:	SONRISA SENIOR LIVING		FACILITY NUMBER:	315920051
ADMINISTRATOR:	CLYMO, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1031 ROSEVILLE PKWY		TELEPHONE:	(279) 213-0047
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	199	CENSUS: 144	DATE:	07/16/2026
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Michael Clymo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff did not provide resident's special diet.
Facility staff did not provide resident with assistance with activities of daily living.

INVESTIGATION FINDINGS:

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On 7/16/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Exec. Dir. (ED), Michael Clymo, to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records, first responder records, room inspection and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

The investigation found that on 5/14/26, R1 experienced an unwitnessed choking incident during breakfast in their apartment between approximately 8:45 AM and 8:57 AM.

S1 reported that they were assigned to R1 on 5/14/26 AM. S1 reported that they had assisted R1 with morning activities of daily living (ADLS). S1 had delivered breakfast which contained an omelet, turned the TV on for R1, cut breakfast to “small bites” and presented the food to R1, who was seated in a recliner.
Report continued...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260518103141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SONRISA SENIOR LIVING	FACILITY NUMBER: 315920051
	VISIT DATE: 07/16/2026

NARRATIVE

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Therefore, on 5/14/26, R1 was served food that exceeded the “Diced size” agreed to and S1 provided food to R1 without the agreed to supervision for R1 while eating.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility.
As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

Report reviewed with Admin. Copy of this report and appeal rights provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260518103141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SONRISA SENIOR LIVING	FACILITY NUMBER: 315920051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/17/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met based on	1 2 3 4 5 6 7	Executive Director agreed to submit a plan for inservice regarding the failures in this case to review proper proccedures for: observed need/ risk, reappraisal, plan updated and staff communication with management regarding care needs by the POC date of 7/17/26.
	8 9 10 11 12 13 14	records and interviews. On 5/14/26, caregiver S1 did not provide R1 with properly prepared food or supervision required for R1's safety while eating. This posed an immediate risk to R1.	8 9 10 11 12 13 14
Type A 07/30/2026 Section Cited CCR 87555(b)(10)	1 2 3 4 5 6 7	General Food Service Requirements (b) (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement was not met based on interviews. Witnesses at the time of R1's choking on 5/14/26, said in statements that food that R1 choked on	1 2 3 4 5 6 7	Executive Director agreed to submit a plan which identifies procedures to be followed when there is an identified need or preference , that kitchen staff prepare the food vs caregiver discretion and preparation by the POC date of 7/17/26.
	8 9 10 11 12 13 14	was not cut to diced size. This posed an immediate risk to R1.	8 9 10 11 12 13 14

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: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260518103141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SONRISA SENIOR LIVING	FACILITY NUMBER: 315920051
	VISIT DATE: 07/16/2026

NARRATIVE

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S1 then left R1 with their food while S1 was called away to assist another resident. S1 stated in interview that they were aware that there was an agreement between R1’s family and the care team that R1 was to be supervised when eating. S1 stated that they planned to only be gone for “a few minutes” and that R1’s 1:1 aids were due to arrive. S1 stated that they heard a call for assist to R1’s room moments after they left but S1 could not return to assist R1 due to the care needs of another resident.

At 8:57 there was a pendant call for assistance. Interview with private caregiver (PC) for R1 stated they arrived at R1’s room, the door to R1's room was open, R1 was slouched in their reclined, R1's lips were blue and R1 had food on them from possible vomit or fell out of their mouth.
PC stated that some of the food on R1 appeared to have been larger than bite sized pieces.
PC began Heimlich from behind R1 with R1 still in a large recliner. PC pressed R1's pendant and knowing that could take some time, they also called to the Resident Care Coordinator (RCC) and the med tech as they knew their numbers as a past employee.
RCC, Christina Aldana (Carderas), and med tech (S6) arrived and R1 was moved to the floor with first aid continuing.
PC scooped more egg, of variable sizes, from R1's mouth.
R1's airway cleared enough for R1's breathing to continue. First responders arrived at the community at 8:56 AM on 5/14/26 and took over aid to R1 upon entry to R1’s apartment.

Report continued...

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260518103141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SONRISA SENIOR LIVING	FACILITY NUMBER: 315920051
	VISIT DATE: 07/16/2026

NARRATIVE

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ensure proper eating and dining experience. Associate will provide assistance with opening containers, cutting food or using utensils/ adaptive equipment as needed. R1’s Service Plan also designates bathing support by private caregivers.

R1’s family had established private caregivers to be with R1, 12 hours per day, 7 days per week.
According to caregivers and med techs interviewed, the meal plan is for facility staff to deliver R1’s meals and to not present to meal to R1 unless/ until the private caregiver is present to monitor and assist R1 with eating as needed.
Care givers and med techs stated that they received that instruction with the agreement of the facility’s RCC, and that it was communicated to all staff who provide care to R1.
Interview with RCC found that R1 had a change of condition weeks prior to choking on 5/14/26. R1 was observed to have significantly increased difficulty chewing, pacing and swallowing before putting more food or drink on their mouth. RCC stated that family of R1 was encouraged to seek a swallowing assessment. In response to the food management deficit by R1, staff were to cut foods to small diced and to have care staff or PCs monitor/ assist R1 while eating or drinking.
While supervision of R1’s meals was not explicitly stated in the Service Plan Report, family of R1 had received agreement to this plan from the facility’s care coordinator “and other”.

In April 2026, R1’s family representative met with the facility’s Resident Liaison and RCC to create a care checklist to be posted in R1’s room. The checklist states “Ensure eggs/ potatoes are DICED bit sized”.
Diced food is defined as .5 inches or smaller. Report continued...

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 59-AS-20260518103141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SONRISA SENIOR LIVING	FACILITY NUMBER: 315920051
	VISIT DATE: 07/16/2026

NARRATIVE

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Emergency responder notes stated: …(R1 was) lying supine on the ground unresponsive with shallow respirations. Upon arrival, staff stated that prior to calling 9-1-1 the patient was eating eggs when (they) started choking and went unresponsive…Staff stated that they performed chest compressions for approximately 4 minutes before the patient spit up some of the eggs. E7 assessed the patient and found egg still in their airway… airway cleared via suction and due to inadequate respiration an Igel was placed…

Emergency notes from the treatment hospital noted: Visit diagnosis- Cardiac Arrest due to unspecified cause and Aspiration of food into trachea. Additionally, the hospital report stated: (R1) is a 91 female with dementia and Parkinson's disease who presents with unresponsiveness after choking.
At (their) senior living facility this morning (5/14/26) (they) choked while eating eggs and became unresponsive. Staff initiated CPR for less than 2 minutes and removed food material from (R1’s) mouth. By EMS arrival (R1) was breathing spontaneously but remained unresponsive with abnormal respirations. EMS found a large amount of egg material in the airway above the vocal cords, which they suctioned with improvement in respiratory rate to about 10/min. (R1) was bradycardic to the 30s, improving to the 60s, and blood pressure stayed above 90 mmHg with a last value near 120/84. Blood glucose was 226. EMS reports that at baseline (R1) is ambulatory, verbal, and mildly confused.

R1’s Service Plan Report notes, under Eating/Meals/Hydration, updated on 8/21/25: Care associates will report any changes in ability to eat independently. Care associates will provide occasional prompting or cueing, encouraging words, and monitor resident to
Report continued...

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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