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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:33:00 PM

Substantiated


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
03/20/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230320174301
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:0CENSUS: 0DATE:
06/13/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Georgina RodriguezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Questionable Death
Facility does not have enough staff to meet the needs of residents
Residents were left in soiled clothes/bedding overnight
Residents call lights were not answered during NOC shift
Nonfingerprinted person were allowed into the facility during NOC shift
NOC shift staff abandoned shift
Resident Records are incomplete
Facility failed to notify CCL of incidents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson met with Licensee Georgina Rodriguez via Microsoft Teams due to the facility being closed effect 04/12/2023.

The department has determined the following as it relates to the above aforementioned allegations.

Questionable Death
Resident 1 (R1) had two choking incidents between 01/2023 to 03/2023. Staff performed the Heimlick Maneuver both times. The second choking incident, the Heimlich Maneiver did not clear R1's airway, and 9-1-1 was called.

Continues on LIC 9099 C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 27-AS-20230320174301
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: 06/13/2023
NARRATIVE
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...Continued from LIC 9099
On 03/20/23, R1 was served breakfast in R1's room by Staff 1 (S1), who left R1 along with R1's food and closed R1's door. Staff 2 (S2) arrived to the room later to give R1 medications and was found unresponsive. S2 called for other staff to assist and called 9-1-1. S2 thought R1 choked and thought R1 was already dead when found. S3 told S2 to hang up and call hospice because R1 was on hospice. The ambulance was turned away at the facility gate. Direct staff interviews showed that kitchen staff were aware R1 was a choking risk, and were told to cut up R1's food. Kitchen staff denied they were aware R1 was a choking risk.

An autopsy was conducted which notes R1's cause of death as Asphyxia, due to foreign body obstruction of airway. Other significant conditions include, cerebral atrophy, cardiac hypertrophy, and focal coronary atherosclerosis. Circumstances of death notes that R1 was found at the assisted living facility with food in
R1's mouth obstructing the airway. According to facility files, R1 reportedly had senile degeneration of the brain, and medical history is unknown. Hospice records noted that R1 had a history of choking and scarfing down his food. Hospice nurses reported that facility staff were aware of R1's choking history and knew that R1 should be fed, watched while eating, and fed soft food.

Due to the facility staff's neglect/lack of care and supervision, it resulted in the death of R1. This poses an immediate health, safety, and personal rights risk to residents in care. Licensee was made aware that a civil penalty will be assessed today in the amount of $500.00. Licensee was informed that additional civil penalties may be assessed at a later date.

Facility does not have enough staff to meet the needs of residents
The department made facility visits on weekly basis. On 03/03/23, the facility was cited 87705(c)(5) for not ensuring an adequate number of staff were available to meet the residents in care. During that time the facility had 2 direct care staff and 1 medication technician to assist with 50 residents in care. The facility attempted to correct by moving residents off of the 2nd floor. The number of residents do not change even though they are moved in a convenient location. According to staff interviews and picture record review, they were consistently short staff. Staff went from working 8-hour shifts to 12- hour shifts, and at times would need to pull doubles. The facility failed to correct the deficiency on 03/06/23, 03/23/23, 03/28/23, and 04/02/23 visits.
Continues on LIC 9099 -C...
This report was amended to reflect that civil penalties were assessed in the amount of $500.00
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20230320174301
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: 06/13/2023
NARRATIVE
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Continued from page 2

Residents were left in soiled clothes/bedding overnight | Residents call lights were not answered during NOC shift
On 03/17/23, S2 came in for AM shift. Upon arrival, S2 found S4 laying on a bed. S2 later learned that multiple residents were not looked after during the shift. S2 and S6 informed S4 to complete their duties and assist the residents that had been ignored. S4 changed 1 resident and then left with S5. According to S6, S6 left a pen mark on the back of one of the resident's briefs prior to leaving the AM shift. S6 came back the next day and saw the resident with the same brief on. According to records and interviews, S4 and S5 quit that day.

On 04/02/23, the department conducted a visit during NOC shift and arrived at 5:00 AM. Observations of the 1st floor included: 2 residents sleeping in the dinning hall, 2 residents walking the hallways, and 0 staff on the first floor. The residents were not being redirected nor did staff have urgency to assist them.

Non-fingerprinted person were allowed into the facility during NOC shift
According to interview with S3, NOC shift staff would bring in their children during the shift due to no childcare. According to records review, S5 arrived to the facility on 03/17/23 with a person who did not work at Sonora Senior Living. S5 took the person inside. It was unknown how long the individual was inside the facility.

NOC shift staff abandoned shift
Facility records and interviews confirmed that on 03/14/23, S4 was on shift during NOC shift. According to S4, S4 was not feeling well and informed management that S4 was leaving. Management request S4 stay until coverage arrived. When S6 arrived, S4 had already left and did not see S4's car or belongings.

Resident Records are incomplete
R1's file was obtained. According to facility records, R1's LIC 602 and Needs and Service Plan was dated 08/30/2022. R1 had multiple documented incidents of hitting clients, but R1's LIC 602 and Needs and Service Plan were never updated.

Continues on LIC 9099 - C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20230320174301
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: 06/13/2023
NARRATIVE
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Continued from Page 3

Resident Records are incomplete

According to interview with Temporary Manager S7, S7 reviewed the medication room files for all residents. S7 found multiple medication administration records to be incomplete. Records were missing signatures and this appeared to be going on for a while.

Facility failed to notify CCL of incidents

On 03/17/23, LPA Valerio received a call from an outside agency regarding the death and incident. LPA was not informed by the facility. On 03/20/23, LPA Valerio retrieve facility documentation. S3 provided LPA Valerio 2 incident reports including an SOC 341. Incident reports were sitting on the Administrator's desk to be reviewed. On 04/02/23, LPA Valerio conducted a site visit were 9 incidents from 03/23/23 -04/02/23 were unreported. Incidents that occurred were written by staff; however, they were not faxed. According to a file review of the electronic facility files, the department did not receive any incident reports from the facility.

Based on interviews, facility record review, medical record review, and observations, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was provided. Licensee to review, sign, and return to LPA.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20230320174301
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights... (a) In addition to the rights listed in Section 87468.1,..residents..shall have..:(4) To care, supervision, and services that meet their individual needs and are delivered by staff...This requirement was not met as evidenced by:
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Licensee stated they will review section 87468.2 and submit a statement acknowledging understanding of regulations by POC due date.
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Based on medical record review, due to the neglect/lack of supervision by staff, R1 died in the care of Sonora Senior Living staff. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
06/14/2023
Section Cited
CCR
87705(c)(4)
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87705 Care of Persons... (c) Licensees who accept and retain residents... shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s... This requirement was not met as evidenced by:
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Licensee stated they will review section 87705 and submit a statement acknowledging understanding of regulations by POC due date
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Based on observations, interviews, and records review, the licensee did not ensure there were an adequate number of staff during 4 out of 4 facility visits.
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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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20230320174301
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2023
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights... (a) In addition to the rights listed in Section 87468.1,..residents..shall have..:(8) To be free from neglect...This requirement was not met as evidenced by:
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Licensee stated they will review section 87468.2 and submit a statement acknowledging understanding of regulations by POC due date
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Based on records review, observation, and interviews, the licensee did not ensure 2 out of 3 staff completed resident ADL tasks during their scheduled shift. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
06/14/2023
Section Cited
CCR
87355(e)
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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:...This requirement was no met as evidenced by:
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Licensee stated they will review section 87355 and submit a statement acknowledging understanding of regulations by POC due date
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Based on records review and interviews, the licensee did not ensure all persons entering the facility, whom were not exempt, to be fingerprinted prior to entering the facility. This poses an immediate health and safety risk to residents in care.
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The licensee was informed violation of Section 87355(e) shall result in an assessment of civil penalties of one hundred dollars ($100) per violation... by the Department. Licensee was made aware an assessment of $100 will be assessed.
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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20230320174301
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (1) The licensee shall arrange, or assist in arranging, for care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee stated they will review section 87465 and submit a statement acknowledging understanding of regulations by POC due date
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Based on observations and interviews, the licensee did not ensure to have a plan to hear or see call lights when reception staff were not available. This poses a potential health, safety, or personal rights risk to residents in care.
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Type B
06/23/2023
Section Cited
CCR
87415(a)(2)
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87415 Night Supervision (a) The following persons providing night supervision ...(2)In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty... Another employee shall be on call.. This requirement was not met as evidenced by:
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Licensee stated they will review section 87415 and submit a statement acknowledging understanding of regulations by POC due date
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Licensee did not ensure S4 did not leave the premises until another staff member came to cover S4's shift. This poses a potential health, safety, or personal rights 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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20230320174301
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87506(a)
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87506 Resident Records (a) he licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...This requirement was not met as evidenced by:
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Licensee stated they will review section 87506 and submit a statement acknowledging understanding of regulations by POC due date
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Based on observations, records review, and interviews, Licensee did not ensure resident facility records or medication administrator record was maintained current and completed, which poses a potential health and safety risk to residents in care.
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Type B
06/23/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency ... This requirement was not met as evidenced by:
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Licensee stated they will review section 87211 and submit a statement acknowledging understanding of regulations by POC due date
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Based on observations and records review, the licensee did not ensure to report incidents via a written report or verbal communication to community care licensing
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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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8