552700409-3-21-2023-27-AS-KHOS-CQKN9L-20230404101608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 03/21/2023
Date Signed: 03/21/2023 05:23:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221110081259

FACILITY NAME:	SONORA SENIOR LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	MICHAEL MALONEY		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 46	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Facility Staff		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff's neglect/lack of care and supervision resulted in Resident 1 sustaining a fracture while in care.
Facility not following physician's orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to the facility to deliver complaint investigation findings. LPA met with facility staff W. Wolski, and explained the purpose of the visit.

The department conducted an investigation and has determined the following as it related the above forementioned allegation.
On 11/05/2022, at approximately 2100 hours, Staff 1 (S1) and Staff 2 (S2) heard a scream from a bedroom. Staff found Resident 1 (R1) on the floor in Resident 2's (R2) bedroom. R1 was seen at Adventist Health Sonora and was diagnosed with a "fracture of proximal end of tibia and knee pain". Per R1's Physician Report, R1 has wandering behaviors and is confused/disoriented. R1 is not able to independently transfer to and from bed. However, per R1's Appraisal/Needs and Service Plan, R1 is able to wheel R1 independently and has a history of roaming and wandering into other residents' rooms. R1's responsible party reported that there are not enough staff at the facility and staff appear to be busy.
Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221110081259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/21/2023

NARRATIVE

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Continued from LIC 9099

R1 was interviewed but was unable to provide a statement and continuously stated R1 did not know or R1 did not remember Sonora Senior Living. R2 was interviewed and did not recall the incident or know who R1 was. Per R2's Physician Report, R2 is occasionally confused/disorientated. It was report by staff that R2 does not have a history of abusing clients. However, R2 does like people in R2's space. Other residents at the facility were interviewed and did not have any concerns about the staff. S1 and S2 were interviewed and advised that when the initial check was conducted R1 was in hR1's bed. Staff reported that it was normal behavior for R1 to go into other resident's room. If staff saw R1 go into someone else's room they would redirect her. Staff reported when they heard R1 scream they responded right away.

The department has determined the following as it relates to the allegation of the facility did not follow physician's orders. According to Resident 1 (R1)'s physician report dated 09/09/2022, R1 is noted to have wandering behaviors, is confused/disoriented, is not able to independently transfer to and from bed, is considered non-ambulatory, and has dementia. According to R1's Appraisal/Needs and Service Plan dated 11/10/2021, R1 uses a wheelchair to get around and is noted to be a wanderer. R1 is on room checks, which staff are to make sure R1 is not "messing with other resident's items". Staff is advised to redirect R1 when R1 is in other residents rooms, is noticed outside, or is out of their site for too long. According to staff interviews, staff check on residents every two hours, with the exception of residence on hospice and residents on 30 minute checks due to injury or incident. Resident's on 30 minutes checks are documents on a 30 minute check sheet that are turned into the medical aids. When asked for documentation for R1's 30 minute check log, the facility was unable to provide this to the department. R1 sustained a fracture in R1's nose and fracture of proximal end of tibia and knee pain. According to discharge medical records, the facility assisted the resident to the follow up appointments in December and January of 2023.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was held with Facility Staff W. Wolski, and a copy of the report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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