552700409-5-20-2021-27-AS-SDOB-C37VGA-20210520162514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 05/20/2021
Date Signed: 05/20/2021 04:27:14 PM

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 LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	KATRYNA HUNT		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 60	DATE:	05/20/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mike Maloney, Licensee/Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Non-Compliance Conference was conducted on this day in the Sacramento South Regional Office via WebEX, due to COVID 19 precautions. The purpose of this Non-Compliance Conference meeting was to discuss the high volume of complaints/inability to remain in substantial compliance with the regulations/or specific incident that has occurred in the last 24 months and capacity increase request. Present in the meeting was Regional Manager Krystall Moore, Licensing Program Manager (LPM) LPM Stephenie Doub, LPM Liza King, LPM Stephen Richardson, Licensing Program Analyst (LPA) Sarah Hurt, Licensee/Administrator Mike Maloney and Resident Care Coordinator Maranda Escobedo. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. Since the facility was licensed on 5/10/2019, facility has been cited thirteen type A deficiencies. The facility was cited for the following issues Personal Rights, Incidental Medical and Dental, Care of Persons with Dementia, Hospice Care of Terminally Ill Residents, Managed Incontinence, Prohibited Health Conditions, Basic Services, Administrator Qualifications and Duties, Conduct Inimical, Plan of Operation, Emergency and Disaster. The facility has also been cited seven type B citations. *Issues discussed during the meeting were:* · The amount of complaint's filed against this facility since licensure. · Residents being left soiled for long periods of time · Supervision issues · Incomplete records · AWOLs · Medications not being administered per policy

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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
	VISIT DATE: 05/20/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

· Resident rooms not being kept clean
· Not notifying Hospice of change in condition
· Retaining a resident with a prohibited health condition
· Not following resident care plans
· Not complying with the local health department and CCL requirements for response testing for residents in COVID positive facilities in a timely manner.
· Not providing transportation
· Fire drill not documented as being completed
· No Emergency and Disaster plan at facility
· Administrator Qualifications and Duties
· Request to increase capacity

The facility has stated they will do the following to achieve continued and substantial compliance:

· The previous Executive Director/Administrator was terminated
· The Executive Director will be present at the facility 40 hours a week
· Submit LIC500 Personnel Summary for facility to include the Administrator presence for 40 hrs
· Submit LIC308 Designation of person(s) in charge in the absence of the Administrator
· Submit incontinence and body check forms created to observe changes in the residents and keep completed copies in the resident file 6/15/2021.
· Conduct re-appraisals for all residents for each facility by 6/15/2021 hiring more staff if necessary
· Continue provide supervision for those with wandering behaviors in accordance with their care plans.
· Submit proof of staff training in the areas of observation, incontinence, personal rights and AWOL by 6/15/2021.
· Conduct fire drills monthly and keep records of completion
· Increased monitoring
· Facility was agreeable to Technical Support Program (TSP)

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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
	VISIT DATE: 05/20/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. An exit interview was conducted with Mike Maloney and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3