552700409-5-12-2021-27-AS-SDOB-C36NHM-20210519102859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 04/29/2021
Date Signed: 05/12/2021 08:35:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2021 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210218135527

FACILITY NAME:	SONORA SENIOR LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	KATRYNA HUNT		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 60	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Wanda Wolski		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not properly maintain a resident's room while in care
Resident sustained unexplained injury while in care
Resident was unkempt for an extended period time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced complaint visit to the facility to investigate and to deliver findings for the above allegations. LPA Johnson was met by Wanda Wolski. LPA toured the facility specifically R1's room.

Allegation: Staff did not properly maintain a resident's room while in care . Based on records reviewed and interviews conducted the facility did not properly maintain residents room. R1 has been identified as having behavior challenges and can be difficult to reason with, however, the facility excepted R1 with the history revealed during the pre-admission assessment dated 10/6/2020. The facility therefore must provide R1 with a plan to maintain his environment to be clean, sanitary and in good repair at all times. The facility observed R1 for two days as he continued to have incontinence accidents and a high fever, before sending him out to the ER were he was diagnosed with an Urinary tract infection, Covid-19 and was also treated for Cellulitis.

Continued on the attached 809C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210218135527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/30/2021 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	Personal Rights 80072 (a) (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide an in-service trainings for all staff. The training shall include: Personal rights(a) 1 thru 4. Proof of training shall be sent to LPA when completed
	8 9 10 11 12 13 14	Based on interviews and record review, Staff did not properly maintain a resident's room while in care, Resident sustained unexplained injury while in care Resident was unkempt for an extended period time which poses an immediate health and safety and personal rights risk to clients in care.	8 9 10 11 12 13 14	The licensee will provide LPA with a date and time for the training by the POC date 4/30/2021
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	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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210218135527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/29/2021

NARRATIVE

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Allegation: Resident sustained unexplained injury while in care. Based on records reviewed and statements from the ER personal, R1 sustained minor injury to his genitals due to being left in urine and fecal matter. R1 was diagnosed with an Urinary tract infection, Covid-19 and was also treated for Cellulitis. R1 was discharged with antibiotics and topical ointment.

Allegation: Resident was unkempt for an extended period time. Based on records reviewed and interviews conducted R1 was found by the paramedic at the facility sitting in a chair in his room with his pants down around his legs, bent over trying to reach his ankles, covered in fecal matter and urine. The stench of feces and urine was so strong the paramedics could smell it outside his room with the door closed.

The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22.

Failure to correct the deficiency may result in civil penalties.

Appeal rights were provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

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