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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:55:57 AM


Document Has Been Signed on 04/06/2023 11:55 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:
04/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ernest GibsonTIME COMPLETED:
12:15 PM
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Licensing Program Anlayst (LPA) Christina Valerio, LPA Arielle Pascua, and LPA Kimberly Viarella arrived to the facility unannounced to conduct a case management - health and safety check. LPAs met with administrator Ernest, and explained the purpose of the visit.

The facility is currently under a Stipulation and Waiver; And Order (CDSS. No. 8121356104). As of today, the Licensee has not identified a buyer to the department.

LPAs toured the facility inside and outside to ensure compliance of Title 22 regulations. LPAs observed the facility to have a food supply sufficient to meet the requirements of 7 days of non-perishables and 2 days of perishables. Facility staff were observed to be organizing the pantry and cooking lunch. Today's lunch will be orange chicken, rice, vegetables, chocolate pudding, juice, and water.

LPA Valerio requested a copy of the updated register of facility residents. In addition to the required information on the form, LPA requested additional information be added to the roster.

LPA Valerio reminded Administer Ernest of the POC due today from 04/02/23 visit. Administrator stated that the auditory devices are present and they will be installed by the end of the visit. LPAs observed the devices on the doors, pictures were obtained.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during today's visit. An exit interview was held, 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: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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