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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:51:08 PM


Document Has Been Signed on 03/02/2023 02:51 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:
03/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Facility StaffTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and LPA Arielle Pascua arrived unannounced to the facility to conduct a case management visit. LPAs met with facility staff and explained the purpose of the visit. LPAs toured the facility inside and out to ensure compliance of Title 22 regulations. Today, there were 3 caregivers and 1 Medication aide scheduled to work on the floor for 50 residents in care. According to lead staff, resident care coordinator and human resources manager are back up if the floor staff need assistance. During a walk through, LPAs observed all 3 floor staff on the 1st floor assisting residents to and from the dinning hall and assisting residents in need. Lunch today was cream of mushroom gravy chicken, rice, and canned corn.

LPAs observed the kitchen areas. LPAs observed 4 kitchen staff. LPAs observed the refrigerators and freezers. LPAs obtained pictures of the food supply. The facility does not have a two day supply of perishables enough for 50 residents in care. LPAs observed 3 cartons of milk, 36 eggs, 6 oranges, 1 bundle of bananas. According to staff, the food delivery from Sysco Foods is supposed to come every Wednesday. Yesterday, the order was canceled due to an outstanding balance. According to records, Licensee Gina paid Sysco foods on 02/28/23 at around 7:01 PM in the amount of $10,575.80. The licensee is supposed to pre-pay Sysco foods $13,500.00 due to non-compliance in the past. According to staff, the facility is expected to receive a food delivery on 03/02/23 between 4:00 PM - 8:00 PM. During the tour, LPAs observed fire extinguishers out of compliance, expiration date 02/23/2023. There were a few extinguishers with an expiration date of 03/25/23. Pictures were obtained for records. Today, An immediate civil penalty in the amount of $500.00 was assessed for violations of Sections 87203. The Facility Designated Administrator was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected. LPAs observed cleaning supplies in an unlocked room. This poses an immediate health and safety risk to residents in care.
Per California Code of Regulations, Title 22, deficiencies are being cited today on LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with staff, and report was provided,
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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Document Has Been Signed on 03/02/2023 02:51 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2023
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal..This requirement was not met as evidenced by:
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Licensee stated fire marshal will be contacted to inspect and renew all fire extinguishers. LPA to received confirmation of services by POC due date.
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Based on observations, fire extingushers on the 1st, 2nd, and 3rd floor were observed to have last service check on 02/23/22. These extingushers are due for its annual inspection, which poses an immediate health and safety risk to the residents in care.
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Type A
03/03/2023
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2)... cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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Licensee stated all staff will be trained on section 87705 and licensee will ensure all cleaning supplies will be inaccessible to residents in care. LPAs confirmed door was locked prior to exiting the facility.
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Based on observations, LPAs observed an unlocked door on the 2nd floor that had 2 cleaning supplies laying on the counter, which poses an immediate 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: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
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