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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:50:38 PM


Document Has Been Signed on 02/17/2023 03:50 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:
02/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ernest GibsonTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct case management visit to follow up on a concern from a past complaint. LPA met with Administrator Ernest Gibson, and explained the purpose of the visit.
 
LPA Valerio was following up 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. LPA provided supportive documents to Licensee Gina and Administrator Ernest on January 04th, 2023. The responsible party was called on 01/25/2023 by Administrator Ernest to discuss clearing the POC. Since that phone call, the licensee has not made attempts to clear the plan of correction. Licensee Georgina Rodriguez sent an email to the department on 01/27/23. In Licensee Georgina's email, she stated the following, "…I'm willing to pay for the bed with a receive provided and taking into consideration the wear out of the bed, I truly do not believe you or the family that this frame cost as much as they are stating."

According to the deficiency page from complaint 27-AS-20220930130144,  the plan of correction stated, "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."

To this date, the family has not been reimbursed for the bed frame. Based on this information, a deficiency is being cited today on LIC 809 -D. Failure to correct this deficiency may result in civil penalties. 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: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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 02:24 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/19/2023 05:20 PM

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: 02/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited

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87218(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident...lost resident property at its current value. The licensee shall... efforts to meet each requirement specified in Section 1569.153.The following requirement has not been met as evidenced by:
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Licensee stated administrator will make contacts with responsible parties to clear plan of correction from 10/14/2022. LPA to receieve an update regarding reimbursement to reporting party by POC due date.
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Licensee misplaced bed frame for Resident 1, and failed to add Resident 1's bedroom set to LIC 621 Client/Resident Personal Property and Valuables form, and did not ensure the plan of correction was completed, which poses a potential health, safety, or personal rights risk to residents in care.
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This report was amended to reflect correct POC due date and POC plan

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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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