552700409-6-13-2023-27-AS-KHOS-CT7NDC-20230627102206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:30:02 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
12/16/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221216090727

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:	0	CENSUS: 0	DATE:	06/13/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Georgina Rodriguez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not maintain facility clean and sanitary
Staff did not meet resident's incontinence needs
Staff did not ensure that hazardous material is inaccessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio contacted Licensee Georgina to discuss findings for the complaint findings. The licensee was issued a Temporary Suspension Order on 04/12/23 and closed with no residents in care. The department has determined the following as it relates to the aforementioned allegations.

LPA observed the facility on 12/20/22, 01/25/23, and 02/08/23. On 12/20/23, a room was observed to have wet stains on the floor, there were used cups on one of the common area tables, and there were used gloves bundled up near a window seal. On 01/25/23, the kitchen floors had food crumbs before lunch service, the floor were sticky, and the 1st floor smelled of urine. On 02/08/23, the stairway was malodorous along with cigarette buds outside on the patio. The facility has one housekeeper to maintain all floors of the building. In addition to the housekeepers regular duties, LPA often observed the housekeeping staff assisting direct care staff with assisting residents.
Continues on LIC 9099 - C…

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023

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 4

Control Number 27-AS-20221216090727

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

LPA interviewed staff. Staff report that they are short staffed and are doing the best they can to get to every resident. Staff interviews expressed frustration that they cannot get to every resident at times. 2 out of 3 staff interviews revealed that staff are to check on resident's every 2 hours. At times, this may or may not be completed. A check would include staff checking to see if a resident used the restroom or needed assistance with any Activities of Daily Living (ADLs). 1 out of 3 staff reported that they check the residents in between the 2 hour window. According to an interview with Administrator Ernest, the resident in question had a hospice nurse that cared for the resident. Administrator stated he was conducting an internal investigation; however, findings of the internal investigation was not shared with LPA Valerio. LPA Valerio reviewed resident records for the resident on hospice. The log showed 2 entries on 12/13/22, 1 entry on 12/14/22, 1 entry on 12/14/22, 2 entries on 12/16/22, and 2 entries on 12/17/22.

LPA Valerio reviewed photos from the facility. The first picture is a picture of a pink and white stripped piece of clothing that appears to be on the floor. The piece of clothing has a large smear of feces covering the clothing piece. The second photo is a picture of a black trash can filled with syringe needles, medical supplies, and prescription bags. Medical supplies are plastic small tubes with a blue cover piece and a large plastic cup. The third photo is a picture of the black trash can with a used wipe, which had feces on the wipe. The trash cans do not have trash bag linings.

Based on interviews, 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 to facility representative. A signature will be obtained on the hard copy.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20221216090727

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 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will review section 87303(a) and send a written letter acknowledging understanding of regulation.
	8 9 10 11 12 13 14	Based on observations, the licensee did not ensure to maintain the facility in a clean, safe, or sanitary manner during licensing visits. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/23/2023 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan ...shall be developed by each facility....(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will review section 87465(a)(2) and send a written letter acknowledging understanding of regulation.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure the facility was able to provide assistance to meet the needs of the residents, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20221216090727

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)(9)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (9) The licensee shall ensure that infection control practices are maintained in the facility.. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will review section 87465(a)(9) and submit a letter acknowledging understanding of regulation
	8 9 10 11 12 13 14	Based on picture record review, the licensee did not ensure medical waste, PPE,medical supplies, and garbage was properly disposed, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

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