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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 02:51:59 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 - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ernest Gibson/Facility StaffTIME COMPLETED:
03:15 PM
NARRATIVE
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On 02/17/23, Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit to follow up on an incident received at the Regional Office. LPA met with Ernest Gibson, and explained the purpose of the visit. Due to time constraints, LPA had to return at a later date to conclude findings. On 03/02/23, LPA Valerio and LPA Pascua conducted an unannounced visit.

According to the incident report and SOC 341 submitted by the facility, a resident was observed to have bruising on their extremities.  On 02/12/23, Resident 1 (R1) was observed to have bruising on the right arm and left elbow. R1 was able to identify staff that it was Staff 1 (S1) that caused the bruising. R1 informed staff that this was not the first time S1 was rough with R1. On 02/13/23,  additional staff reported observed new bruising on R1. An internal investigation is currently being conducted. R1 stated R1 was tired and had difficulty standing. S1 told R1 to "stand up straight". S1 did not request for assistance from other staff.

According to staff interviews, staff cannot confirm or deny the allegation above is true. Staff also mentioned they did not observe the incident and only heard about it.

The facility is experiencing staff shortages; however, staff are equipped with walkie talkies to inform staff on shift if they need assistance. On this evening, there were only 3 staff on shift to assist and provide supervision for 50 residents.

Records revealed that R1 is on a blood thinner. According to staff files, S1 received training on 08/15/22 on Self-care, resident rights, dementia care, red flags of abuse. According to staff interviews and LPA observation, R1's medical equipment (sit to stand lift) does not work properly and brakes do not work. LPA observed the device and confirm this device brakes do not work.

Based on the above information, deficiencies are being cited today on LIC 809-D. Failure to correct these deficiencies may result in civil penalties. Appeal rights were provided. An exit interview was held with facility staff, 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: 02/17/2023
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 02:51 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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87303 Maintenance and Operation (e) ... fixtures shall be maintained...(6) ...maintained in operating condition. Additional equipment shall be provided in facilities accommodating ...and/or nonambulatory residents, based on the residents' needs. This requirement was not met as evidenced by:
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Licensee stated they look at the device and create a plan to get the device fixed and/or covered by insurance. LPA to received a plan to replace or fix sit/stand lift by POC due date.
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Based on observations, records review, interviews, the licensee did not ensure R1's medical equippment was in working condiition, which poses an immediate health and safety risk to resident care.
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Type A
03/03/2023
Section Cited

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87705 Care of Persons... (c) Licensees who accept and retain residents... shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs... This requirement was not met as evidenced by:
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Licensee stated facility will ensure that a staff to resident ratio of 1:10 will be implemented. LPA to received a staffing schedule and written statment stating their plan to address staffing issues by POC due date.
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Based on observations, interviews, and records review, the licensee did not ensure there was enough staff on shift to meet the needs of residents, 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: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2