552700409-10-14-2022-27-AS-SDOB-CN7SSW-20230118130838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 10/05/2022
Date Signed: 10/14/2022 01:08:40 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 LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	MICHAEL MALONEY		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 60	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Resident Care Coordinator, Maranda Escobedo		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is not providing residents medical care
Facility is not in good repair

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 4

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
	VISIT DATE: 10/05/2022

NARRATIVE

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.............Continued from 9099

Regarding the allegation the facility is in disrepair. Based on LPA observation Room #121 is missing several drawers from the sink vanity. LPA also observed Room # 124 also has a drawer missing from the bathroom vanity. Therefore this allegation is SUBSTANTIATED.

The following deficiencies are being cited today Per Title 22 Regulations,

Exit interview conducted with Resident Care Coordinator Maranda Escobedo and a copy of this report provided.

This report was amended to removed the unsubstantiated verbiage.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 10/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/19/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will send proof of repaired bathroom vanity to LPA by 10/19/2022 POC date.
	8 9 10 11 12 13 14	Room # vanity is in disrepair which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 10/19/2022 Section Cited CCR 87464(f)(6)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (6)Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by	1 2 3 4 5 6 7	Facility corrected this deficiency during the visit. TB test was retaken and logged by facility staff Maranda Escobdedo.
	8 9 10 11 12 13 14	Based on records review and interviews, the facility did not ensure to assist R1 in getting R1's TB test read, which poses a potential health and safety risk to residents in care	8 9 10 11 12 13 14	This report was amended to add the second citation 87464(f)(6)

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 Richardson	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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 LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	MICHAEL MALONEY		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 60	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Resident Care Coordinator, Maranda Escobedo		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility has pest infestation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit on 10/05/2022 to investigate the above allegations. LPA met with Resident Care Coordinator Maranda Escobedo and explained the purpose of today's visit.
Regarding the allegation Facility has pest infestation. Based on LPA interviews, observation, and records reviewed there does not appear to be a pest infestation at the facility. LPA visits the facility weekly and has not noticed an infestation of pests or insects inside the facility. Resident Care Coordinator Maranda Escobedo stated Clark Pest Control visits this facility once a month to ensure there is not a pet infestation at the facility.Therefore, this complaint is UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies are being cited today Per Title 22 Regulations.

Exit interview conducted with Resident Care Coordinator Maranda Escobedo and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4