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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/06/2023
Date Signed: 03/06/2023 01:38:27 PM


Document Has Been Signed on 03/06/2023 01:38 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:
03/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Facility StaffTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a plan of correction (POC) visit. LPA met with facility staff, and explained the purpose of the visit. On 03/02/23, the facility was in violation of Title 22 87303(e)(6) and 87705(c)(4).  The facility was to submit plan of correction to LPA by 03/03/23. As of 03/06/23, the department has not received documentation to clear the POC or a request for an extension for the citations.

87303(e)(6); LPA has not received any plan of correction documentation related to R1's sit to stand device.

87705(c)(4); The facility was to ensure there is a staff to resident ratio of 1:10 to ensure there is adequate number of direct care staff to meet the needs of the residents. LPA did not receive a staffing schedule or written statement to addressing their staffing plan.

As of 03/06/23, the licensee has failed to correct deficiencies. A daily civil penalty of $100 per violation is being assessed today due to plan of correction not being met.

An exit interview was held with facility staff, and a copy of the report was provided via email due to technical printer issues.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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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