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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 04/02/2023
Date Signed: 04/02/2023 06:24:04 AM


Document Has Been Signed on 04/02/2023 06:24 AM - 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: 39DATE:
04/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:00 AM
MET WITH:Facility StaffTIME COMPLETED:
06:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and Regional Manager (RM) Stephenie Doub arrived to the facility unannounced to conduct a case management - health and safety visit.

LPA and RM toured the facility at 5:00 AM to ensure compliance of Title 22 regulations. LPA and RM observed the 3rd floor, 2nd floor, and 1st floor. The 1st floor - bottom floor is designated for residents who need a higher level of care. LPA and RM observed 2 residents sleeping in the dinning hall, 2 residents walking the hallways, and 0 staff on the first floor. The 2 resident walking in the hallways had access to 2 exit doors. LPA/RM push on the doors and exited the building. There was no auditory sound to indicate that the doors had opened. This poses a potential health and safety risk to residents in care. A previous licensing report was issued on 12/20/22 giving notice of the same violation 87705(j). Due to the facility being cited for the same violation within last 12 months, an immediate civil penalty is hereby assessed in amount of $250.00. On the 2nd floor, LPA/RM was met by Staff 1 (S1). S1 was coming out of the medication room and stated S1 is the only person on the floor. LPA/RM observed the 3rd floor - top floor and was met by Staff 2 (S2). S2 stated a staff member called out this morning, which is why 2 direct care staff are on shift.

According to LPA observations, LPA saw 1 staff enter the facility at 4:30 AM and 1 staff leave the facility at 4:45AM. At 5:20 AM, staff for the kitchen arrived for the morning shift. At 5:30 AM, administrative staff arrived to assist in the kitchen due to a cook call out. The facility was cited 87705(c)(4) on 03/02/2023. The facility failed to correct the deficiency on 03/06/23, 03/23/23, 03/28/23, and 04/02/23 visits. 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.

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on LIC 809-D. An exit interview was held, and a copy of the report was provided to facility staff. Appeal Rights Provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2023
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 04/02/2023 06:24 AM - 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: 04/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2023
Section Cited

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Licensee stated the facility will order new auditory devices for the exit doors and place on the doors when they arrive. LPA to receive notification of the installation of the device by POC due date.
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Based on observations, the facility did not ensure 2 out of 4 exit doors were equipped with an auditory device to alert staff. It was observed that staff were not on the floor to observe residents if any residents were to exit the facility. This poses a potential 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: 04/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2023
LIC809 (FAS) - (06/04)
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