552700409-3-28-2023-27-AS-CVAO-CQCS9F-20230328134039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/28/2023
Date Signed: 03/28/2023 01:40:56 PM

Document Has Been Signed on 03/28/2023 01:40 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 LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	ERNEST G GIBSON		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 43	DATE:	03/28/2023
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Ernest Gibson		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived to the facility unannounced to conduct a case management - health and safety check. LPA and LPM met with front desk staff, and explained the purpose of the visit. LPA and LPM conducted a facility tour prior to meeting with Administrator Ernest. LPA observed the 1st, 2nd, and 3rd floor of the building. LPA observed 2 care giving staff on the 1st floor, 3 kitchen staff inside the kitchen area, 1 medication technician on the 2nd floor, and 1 care giving staff on the 3rd floor. The 3rd floor was observed to have a Residential Care Coordinator, Housekeeper, Human Resources Manager, and Administrator Ernest. 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, and 03/28/23 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. During the tour, LPA and LPM checked random residents rooms on each floor and walked on the exterior perimeter. On the exterior deck, a new fence was installed to prevent residents from accessing the exposed and potentially hazardous areas on the deck. This observation clears a deficiency cited [87303(a)] on 03/23/23 visit. LPA walked in Resident 1 (R1) room and did not see resident in room. R1 is usually in R1's wheelchair. LPA asked staff the location of R1. Staff stated R1 was sent out to the hospital on 03/25/23. Staff are not aware of the current status of R1. According to records review of the regional office, the department has not received an incident report regarding R1. Administrator Ernest stated he has 4 SIRs from 03/25/23 that were signed off by Residential Care Coordinator and were pending to be sent. LPA obtained copies for review. Continues on LIC 809 - C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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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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: 03/28/2023

NARRATIVE

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...Continued from LIC 809

Today, staff were observed to be wearing mask throughout the facility tour and during the duration of our visit.

Today, the facility is serving a fajita vegetables, tortillas, Spanish rice, chicken, and apple crumble. Kitchen staff were also preparing milk, juice, and water for residents to drink. LPA and LPM observed the facility to have a supply of food to meet the requirement of 2 days of perishable foods and 7 days of non-perishables. Administrator confirmed that the facility order with Sysco Foods will be delivered tomorrow 03/29/23.

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. This directive was given on 03/23/23 visit and was rewritten as a reminder.

LPA and LPM obtained copies of 1 staff file, updated registry of facility residents, and copy of SIRs from 03/25/23.

LPA and LPM reviewed the updated registry of facility residents and counted 43 residents with 2 residents out in the hospital. According to interviews last week, staff reported 42 residents. Since last week 2 residents moved out and 1 passed away. According to interviews, no new residents have been admitted and the given census last week was not accurate. Correct census is 43 with 41 residents physically in the facility.

Per California Code of Regulations (CCR), Title 22, no citations were observed during today's visit; however, due to previous citations daily civil penalties will continue to accrue as stated earlier in the report. An exit interview was held with Administrator Ernest, and a copy of the report was provided. Appeal Rights provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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