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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 12/12/2022
Date Signed: 12/12/2022 12:12:54 PM


Document Has Been Signed on 12/12/2022 12:12 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SONORA SENIOR LIVINGFACILITY NUMBER:
552700409
ADMINISTRATOR:ERNEST G GIBSONFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: 59DATE:
12/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Human Resources Manager - Wanda WolskiTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace made an unannounced visit to the facility on this day for the purpose of concluding a Case Management visit. LPA met with Human Resources Manager and explained the reason for the visit.

On 3/29/2022, Resident 1 (R1) was found at the facility at approximately midnight with swollen face and bleeding. R1 was sent to the local Emergency Room (ER) and was diagnosed with a nasal fracture. Staff reported that rounds are conducted every two hours on the NOC shift. The first rounds starting at 10:30 PM and occurring every two hours after. Staff 1 (S1) reported that they do rounds at 2230 hours, but on the night R1 sustained their injuries, they were busy and did not complete rounds at 2230. S1 stated that they then completed the next rounds a little earlier an found R1 at approximately 2300-0000 hours. S1 reported that R1’s face was “swollen and black from bruises.” Based on interview with treating Emergency Room physician of R1, it appeared that R1’s injuries occurred about 4-6 hours prior to R1 being seen in the ER.

The following deficiency was cited per California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate civil penalty of $500.00 issued on today's date.

An exit interview was conducted with Human Resources Manager and a copy of this report along with appeal rights, civil penalty, and confidential names list were provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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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Document Has Been Signed on 12/12/2022 12:12 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SONORA SENIOR LIVING
FACILITY NUMBER: 552700409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited

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87208(a)(5) Plan of Operation - Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: Staffing plan, qualifications and duties.
This requirement is not met as evidenced by:
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Licensee agrees to submit a written plan of operation stating how staff qualifications and duties will be performed for residents in the facility. Additional training will be provided for staff regarding duties and a completion date to be provided on POC date. Plan of Correction is due on 12/13/2022
Immediate Civil Penalty of $500.00 is being issued on 12/12/2022.
Christina Valerio
christina.valerio@dss.ca.gov
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The licensee did not ensure that staff completed their duties. Staff did not complete rounds as defined in their duties, which delayed R1 from receiving timely medical attention. This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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