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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 01/25/2023
Date Signed: 01/25/2023 01:18:56 PM


Document Has Been Signed on 01/25/2023 01:18 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: 53DATE:
01/25/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ernest GibsonTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA met with Administrator Ernest, and explained the purpose of the visit.

LPA toured the physical plant. LPA observed all floors of the facility, common areas, and outside patio areas. LPA observed the kitchen area. In the kitchen, there was a tray of food left uncovered. There were no staff around. LPA later came to the kitchen and observed 3 kitchen staff. 2 out of 3 kitchen staff were observed to be wearing a mask. According to staff interviews, resident's have been experiencing stomach issues (i.e. diarrhea) and may or may not have had food poisoning.

LPA observed 2 staff scheduled for the 1st floor, 1 staff scheduled for the 2nd and 3rd floor, and 1 medication technician for all residents. LPA was touring the facility when a Resident 1 (R1) came up to LPA to ask if LPA could help with resident 2 (R2). R2 had fallen out of R2's wheelchair and R1 heard R2 scream. R1 stated the scream was soft so no one could hear R2. LPA looked around and could not find any staff due to staff being busy and on another floor. LPA went to the administrative office and notified office staff. The facility has a call light area for the 1st floor; however, their front desk staff is not in and there is no staff assigned to monitor the call lights.

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited today. Failure to correct these deficiencies may result in civil penalties. 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: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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 2


Document Has Been Signed on 01/25/2023 01:18 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: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited

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 87705 Care of Persons... (c) Licensees who accept and retain residents... shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs... This requirement was not met as evidenced by:

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Licensee stated a plan to assign additional staff for each floor will be sent to LPA by POC due date.
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Based on observations and interviews, the licensee did not ensure there was enough staff on shift to meet the needs of residents. R1 had to notify staff regarding a fall. Without R1 notifying staff, staff would not have known about the fall, which poses an immediate health and safety risk to residents in care.
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Type B
02/08/2023
Section Cited

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87555 General Food Service Requirements (a)... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:
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Licensee stated a training will be held with staff in regard to food handling. Licensee to send a copy of attendance sheet.
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Based on observations, Licensee did not ensure 2 out of 3 staff wore a mask while preparing meals and a tray of food was left out without proper covering. This poses a potential 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: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2