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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/23/2023
Date Signed: 03/23/2023 07:53:43 PM


Document Has Been Signed on 03/23/2023 07:53 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: 42DATE:
03/23/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Ernest GibsonTIME COMPLETED:
08:15 PM
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to the facility to conduct a case management visit to ensure the health and safety of the residents in care. LPA and LPM met with facility staff and Administrator Ernest Gibson, and explained the purpose of the visit.

LPA and LPM toured the facility to ensure the health and safety of the residents in care. The facility was observed to have 3 direct care staff (1 on the top floor and 2 on the bottom floor). There are no residents living on the second floor. There is 1 medication technician scheduled to assist for both floors. The facility was cited 87705(c)(4) on 03/02/2023. The facility failed to correct the deficiency on 03/06/23 and 03/23/23. This poses an immediate health and safety risk to residents in care. Due to this observation, the facility was made aware that a daily civil penalty of $100 per violation is being assessed today due to the plan of correction not being met. The facility will continue to accrue daily civil penalties until the plan of correction has been met.

LPA and LPM observed all floors of the buildings. It was observed that the facility common areas were not clean. The floors on the bottom floor had mud and red stains on the wood floors. The facility deck located outside on the 1st floor had pieces of the floor (rubber roofing material) ripped from the wood, which left the parts of the wood deck exposed. It appears the previous storm caused the material to separate from the deck. LPA took pictures of the floor in the common area and facility outside deck for future reference. The wind caused the pieces to fly toward the right side of the deck near one of the exit doorways. The facility was observed to have areas where the roof is leaking. Areas of leaking were observed in the receptionist office and the door way by the kitchen hallway. Pictures were obtained for reference. According to staff, when it rains, the roof leaks. This poses an immediate health and safety risk to residents in care.

Continues on LIC 809 -C...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


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
VISIT DATE: 03/23/2023
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...Continued from LIC 809
The facility is currently under a Stipulation and Waiver; And Order (CDSS. No. 8121356104). The Licensee has not identified a buyer to the department. The facility administrator was reminded that they need to develop and submit a closure plan. Licensee and Administrator to send a draft closure plan to the department by March 31st, 2023.

During LPA's visit on 03/02/23, "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."

LPA followed up with Licensee Gina via email on 03/01, 03/02, 03/06, and 03/08 on the payment of $13,500.00 to Sysco Food. On 03/08/23, Licensee Gina stated she no longer pays $13,500. Licensee Gina stated "since the new amount was not set and we are letting residents go by the day. Sysco instead wants me to set automatic payments." This information was not relayed to the department. Although Gina stated Sysco and licensee had an agreement to set automatic payments, it is unknown to the department when the agreement was set. According to Sysco foods, they did not deliver on 03/01/23 due to outstanding and unpaid invoices. The facility was not cited on the 03/02/23 visit; however, the information was documented on LPA visit on 03/02/23. The facility will be cited today based on those observations. On today's visit, the facility food supply was observed. Kitchen staff stated they received their weekly food order yesterday afternoon. The facility was observed to have an adequate food supply of perishables and non-perishable foods for 7 days.

LPA and LPM interviewed staff, residents, and responsible parties during today's visit. According to interviews, their is a mixed review on transparency from the facility regarding the current Stipulation and Waiver Order. According to resident and family interviews, they are aware of the order. According to staff interviews, they were not fully aware. Administrator Ernest stated that he held 3 meetings with staff regarding the stipulation and allowed staff to ask questions regarding the stipulation.
Continues on page 3 809 - C...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
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
VISIT DATE: 03/23/2023
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...Continued from page 2 of LIC 809 C

It was observed that the masking mandate was not being followed by staff. It was observed 7 out of 9 staff at the facility were not wearing a mask, which poses an immediate health and safety risk to residents in care.

The 3rd floor, which is also the main entrance floor, has coffee and water made available to residents. LPA and LPM observed staff filling up the coffee maker with water from the bathroom and using the water to make a pot of coffee for residents, which is an immediate health and safety risk to residents in care.

LPA and LPM requested copies of the last 3 months of utility bills. Licensee provided a copy of invoice from ECO Sound Medical Services, which is a Medical Distribution Company and not utility bill. LPM requested Licensee Gina to provide 3 months of utility bills from January 2023 to March 2023 to the Regional Office (RO) as soon as possible and no later than 12:00 PM on 03/24/23.

LPA and LPM observed dinner service. Dinner Service started at 4:30 PM. Staff were observed delivering food trays to the residents who could not come down to the dinning hall. According to resident interview, resident requested a grilled ham and cheese sandwich because resident did not like the crab cakes that were being made. The facility was observed to provide this for the resident, which made the resident happy.

LPA and LPM requested staff files for Staff 1 (S1) - Staff 4 (S4). Staff files showed S4 did not have First Aid Training completed on file. S4 is a NOC shift staff. During NOC shift, there is currently 2 direct care staff on shift after 6:30 PM. Due to this observation, this poses an immediate health and safety risk to residents care.

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on LIC 809 D pages. An exit interview was held with Administrator Ernest, and a copy of the report was provided. Appeal Rights provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/23/2023 07:53 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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Licensee stated Administrator will ensure Sysco order will be arriving on scheduled delivery day of Wednesday. Every Monday and Tuesday, Administrator to confirm with Licensee that the invoice has been paid and delivery will occur. Administrator to send confirmation of delivery by POC due date and every week until further notice.
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Based on observations on 03/02/23 versus observations on 03/23/23, the licensee did not ensure Sysco Foods Co. received a payment in order for the facility to receive their food supply order on 03/01/23, which poses an immediate health and safety risk to residents in care.
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Type A
03/24/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful...This requirement was not met as evidenced by:
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Licensee stated a text message will be sent to the group staff message regarding the masking requirement. A training will be provided to staff regarding the current mask mandate for staff on 03/28/23. LPA to received in-service sign in sheet. LPA to received confirmation of text message being sent by POC due date.
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Based on observation, 7 out of 9 staff working in the building did not have a mask on during their shift, 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: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/23/2023 07:53 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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:
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Licensee stated administrator will schedule a training with staff to go over 87555(b)(9) on 03/28/23. Administrator Ernest will send a message in the group staff chat regarding the instructions on proper way to make coffee for residents and staff and not to use the bathroom water for any consumption. LPA and LPM observed this message being sent during visit.
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Based on observation, the licensee did not ensure the facility followed procedures to protect the safety, acceptability and nutritive value of the preparation of the coffee, which poses an immediate health and safety risk to residents in care.
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Type A
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Section Cited

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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall...(1) ... receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:
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Licensee stated staff will complete training before LPA and LPM leave the facility. LPA and LPM observed staff completing the training and observed the completed certificate.
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Based on records review, the licensee did not ensure 1 out of 4 staff files reviewed had copies of First Aid Training in file. Facility Lead staff admitted that this was not completed. This 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: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/23/2023 07:53 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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee stated the facility will ensure the facility is cleaned in common areas. Facility will reach out to third party contractors to get a quote of the leaks and exterior deck. Licensee to block off areas of concern and ensure residents do not have access. LPA to received confirmation of implemented task by POC due date.
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Based on observations, the licensee did not ensure the facility was in clean or safe condition in the common areas, hallways, and exterior grounds. This 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: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6