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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 01/06/2023
Date Signed: 01/06/2023 01:13:44 PM


Document Has Been Signed on 01/06/2023 01:13 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: 55DATE:
01/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ernest GibsonTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management. LPA Valerio met with Administrator Ernest, and explained the purpose of the visit.

LPA toured the facility to ensure compliance of Title 22 regulations. The second floor flooring is being repaired. LPA observed lunch service. Lunch service 12:00 PM.

LPA observed an emergency supply of food, water, blankets, and towels. Administrator stated they have a back up Tesla generator and flash lights ready in case the power goes out.

LPA spoke to multiple residents and staff during the visit.

LPA observed an incident occur with a resident on the 1st floor. Within seconds, multiple staff assisted the staff with the resident. Within 5 minutes, paramedics arrived to the facility.

Per California Code of Regulations, no deficiencies were observed on today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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