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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:43:11 PM


Document Has Been Signed on 12/20/2022 03:43 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: 57DATE:
12/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ernest GibsonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA met with Ernest Gibson, and explained the purpose of the visit.

LPA toured the facility inside and out to ensure the health and safety of the residents in care. LPA interacted with multiple residents and staff during the visit. For lunch, the residents ate green beans, chicken with gravy, dessert, water, juice, and milk. According to interviews, the facility plans to have activities ready for the holiday weekend.

LPA reviewed ADL logs for the facility, medication documents, and activity records. LPA observed empty spaces on ADL logs and medication documentation. LPA spoke to administrator about policy and procedures regarding these documents. LPA provided Technical Assistance. LPA was informed of projected policies that will be implemented to ensure documentation is completed correctly for Medication and Activities of Daily Living.

LPA followed up on an incident that occurred on 12/16/2022. Resident 1 (R1) had fallen from R1's wheelchair after exiting the building. The exit door was located in the kitchen area. Staff was not aware that R1 was in the area. According to interviews, it was raining and R1 had fallen out of the wheelchair landing on R1's face. R1 sustained injuries on face with blood coming out from wounds. R1 was transferred to the emergency room. LPA interacted with R1 during the visit.

LPA requested a copy of an updated LIC 9020 Register of Facility Clients/Residents.

Per California Code of Regulations, Title 22, deficiencies are being cited today on LIC 809 - D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided. An exit interview was held, and a copy of the report was given to Administrator Ernest Gibson.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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 12/20/2022 03:43 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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Licensee stated they will install an auditory notification device on all exit doors. Licensee to send copy of invoice for the auditory device to LPA by POC due date.
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Based on records review, the licensee did not ensure an exit door near the kitchen had an auitory device to alert staff when the door was opened, which resulted in Resident 1 (R1) exiting the building, falling from R1s wheelchair, and sustaining injuries. 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) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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