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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 01:20:11 PM


Document Has Been Signed on 01/25/2023 01:20 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:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ernest GibsonTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a POC visit. LPA met with Administrator Ernest Gibson, and explained the purpose of the visit.

LPA Valerio was following up an a citation issued on 09/30/2022 for complaint 27-AS-20220930130144. LPA spoke to administrator Ernest regarding the Licensee clearing the plan the correction. Licensee Gina stated that she will pay if she is given a receipt instead of the estimate provided by the family. According to the deficiency page, it stated that "Licensee will submit a written plan to replace Resident 1's bed frame at current value and submit to LPA by 10/14/2022 POC date." LPA provided supportive documents to Licensee Gina and Administrator Ernest on January 04th, 2024. Due to the failure to correct the deficiency, LPA Valerio will assess civil penalties during the visit as the Plan of Correction has not been met. The plan of correction was due 10/15/2022; therefore, a civil penalty of $100 per day will be assessed.
 
An exit interview was held, and copy of the report was provided to current Administrator Ernest. Appeal rights also 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)
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