<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 02/08/2023
Date Signed: 02/08/2023 02:11:02 PM


Document Has Been Signed on 02/08/2023 02:11 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: 50DATE:
02/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Facility Staff TIME COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a Health and Safety Case Management visit. LPA Valerio met with facility staff, and explained the purpose of the visit.

LPA toured the facility. LPA observed the 3rd floor/main entry floor. There was one administrative staff present. Hallways and resident rooms appeared clean. The second floor was observed. The floor remodel is complete. There was a raised bump on one of the vinyl flooring but was marked by a blue tape to ensure a person did not trip. LPA interacted with two residents on the second floor. It was observed that laundry was being completed by staff. LPA observed the bottom floor/1st floor. There were 2 staff present and 1 medication aide. Residents were being assisted by staff. Prior to lunch being served, LPA spoke to kitchen staff. Kitchen staff were observed wearing mask and stated they received their order of food. Today's lunch was enchilada casserole, red rice, refried beans, and ice cream. Residents were given water, juice, and an option for tea or coffee. A medication pass was observed by LPA.

LPA requested the following documentation: Mitigation plan and infection control plan

An exit interview held with facility staff, and a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 1