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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 09/01/2022
Date Signed: 09/18/2022 06:55:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220809101713
FACILITY NAME:SONORA SENIOR LIVINGFACILITY NUMBER:
552700409
ADMINISTRATOR:MICHAEL MALONEYFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: 60DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Resident Care Coordinator, Maranda EscobdedoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is not following COVID 19 protocols
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility September,1 2022 at 12:00 p.m. to conduct an investigation on the above allegations. LPA Hurt met with Resident Care Coordinator Maranda Escobedo and explained the purpose of the visit.

Regarding the allegation facility is not in good repair. Based on LPA observation the bathroom between resident rooms 103 and 104 has a large raised area in the floor, and the side wall has a large empty hole. The raise in the floor comes off the ground a few inches and could potentially be a hazard to any residents that are not stable on their feet. Therefore, this allegation is SUBSTANTIATED.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220809101713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
87470(a)(1)(a)
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87470 Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:
(1) All staff and volunteers shall perform hand hygiene.(A) When conducting hand washing, the method shall include the following: Wet hands with clean water and apply soap. Lather hands by rubbing them together with soap. Lather the backs of the hands, between the fingers, and under the nails. Scrub hands for at least 20 seconds. Rinse hands well under clean, running water. Dry hands using a clean towel (disposable or non-disposable) or air dry. The following requirement has not been as evidenced by:
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Licensee will ensure the facility has hand soap in all common areas of the facility to promote resident and staff handwashing and send proof to LPA by POC date of 09/15/2022.
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LPA observed four of the common facility bathrooms did not have any hand soap which poses a potential health, safety or personal rights 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2