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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 04/03/2023
Date Signed: 04/03/2023 04:36:22 PM


Document Has Been Signed on 04/03/2023 04:36 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: 39DATE:
04/03/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility StaffTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Analyst (LPA) Arielle Pascua arrived to the facility unannounced to conduct a case management - health and safety check. LPA was met by facility staff, and explained the purpose of the visit.

LPA observed the facility to ensure compliance with Title 22 regulations. LPA observed the 1st floor, which was staffed with 2 direct care staff. LPAs observed a line of individuals waiting to be seen by a outside agency podiatrist. LPAs observed that the facility had a adequate food supply to meet the needs of Title 22 regulations. LPA to receive notification from Administrator Ernest on Tuesday or Wednesday to confirm food delivery for this week. LPAs observed the 2nd floor. While walking down the hall, LPAs observed a puddle of liquid. There was no hazard sign to indicate a spill. Since the hallway did not have enough light, LPAs shined a flash light at the liquid puddle. The puddle was yellow in color. This poses an immediate health and safety risk to residents in care.LPAs observed the top floor. There was 1 medication technician, 1 residential care coordinator (RCC), and 1 direct care staff on lunch. According to staff, while the direct care staff is on lunch, the RCC will cover the floor.

According to interviews, the activity director no longer works for Sonora Senior Living. There was a person scheduled to work activities today; however, the person is out today. LPAs observed no activities being conducted throughout the visit. This poses a potential health and safety risk to resident in care.

During the visit, administrative staff was observed assisting a resident on looking at placement options. 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.

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on LIC 809-D. Appeal Rights provided. An exit interview was held, and a copy of the report was provided to facility staff.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023
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 2


Document Has Been Signed on 04/03/2023 04:36 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: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2023
Section Cited

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87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (2)...cleaning and disinfection activities shall be performed... (C) Spills of blood and other potentially infectious materials and surfaces shall be promptly cleaned and disinfected. This requirement was not met as evidenced by:
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Licensee stated the spill will be cleaned up right away and confirmed with carestaff that they were made aware of the spill. Licensee to send a written statement by POC due date to show that they have read and understand the regulations.
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Based on observations, LPAs observed a unknown liquid puddle in the walkway of floor 2, which poses an immediate health and safety risk to residents in care.
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Type B
05/01/2023
Section Cited

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87219 Planned Activities (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities... This requirement was not met ad evidenced by:
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Licensee stated the activities director quit last week and the scheduled activity assistant was schedule but called off today. Licensee to submit a plan along with confirmation of a full-time activity staff on shift to ensure activities are provided to the residents by POC due date. LPA to be sent written acknowledgement of review and understanding of 87210(f).
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Based on observations, the facility did not provide activities to residents in care throughout LPAs visit. 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: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2