<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 02:11:20 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 - IncidentUNANNOUNCEDTIME 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 case management visit. LPA met with facility staff, and explained the purpose of the visit.

On 01/10/2023, the regional office received an incident report regarding a resident (R1) being assaulted by another resident's family member (F1). According to records review, the incident occurred on 01/01/2023. F1 was visiting their family and was visiting in a common area on the first floor/television room. Video footage recorded by the facility shows that F1 was verbally interacting with R1. R1 was in R1's wheel chair and to the left side of F1. F1 gestures F1's middle finger at R1. R1 wheels towards F1. F1 gets up and continues to argue with R1. Audio was not recorded or captured. F1 is then observed using hands to make physical contact with R1's face. R1 throws items on the floor and appears to be agitated. Another resident attempts to intervene with a wooden chair; however, R1 is agitated and tries to throw the chair at the resident. F1 leaves the room to get staff. Two staff members are observed coming in 6 minutes after the incident occurred. Facility staff escorted F1 off the property, called the sheriff department, and contacted upper management.


Based on above information, deficiencies are being cited today on LIC 809-D. Appeal rights were provided. 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: 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 2


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 (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: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated that F1 is no longer allowed to visit the facility. All visitations will be monitored by staff. LPA to receive this policy in writing by POC due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not ensure R1 was assaulted by a visitor in the common area, which poses an immediate health and safety risk to residents in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2