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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 07/19/2023
Date Signed: 07/19/2023 03:25:34 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
01/27/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230127145900
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:
07/19/2023
ANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Georgina RodriguezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Residents are without showers for weeks at a time
Laundry is not being done in a timely manner resulting in residents wearing soiled clothing
Resident files are not completed
Facility does not provide enough staff to assist resident's needs
Facility failed to notify incidents to CCL, Ombudsman, and Responsible Party
Facility failed to seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio met with Licensee Georgina Rodriguez virtually to discuss complaint investigation findings. The facility is closed; therefore, the meeting occured virtually.

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

Residents are without showers for weeks at a time

LPA interviewed staff. Staff 1 (S1) stated there are multiple residents without showers at weeks at a time. S1 has cried to management due to feeling horrible that staff cannot get to all the residents. According to interviews, if a staff showers a resident, there will be no one to watch the floor. Residents are seen with drandruff in hair. Staff 2 stated there is a showering schedule that is never followed because there is not enough staff or time to get to everyone.
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: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
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
01/27/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230127145900

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:
07/19/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Georgina RodriguezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not assisting resident in getting care
Resident has wounds that are not properly care for
Resident has not been moved in months due to Hoyer lift being broken
Resident rental rates are illegally increased
INVESTIGATION FINDINGS:
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3
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5
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7
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9
10
11
12
13
Licensing Program Analyst (LPA) Christina Valerio met with Licensee Georgina Rodriguez virtually discuss complaint investigation findings. The facility is closed; therefore, the meeting occured virtually. The department has determined the following as it relates the above aforementioned allegations.

Facility is not assisting resident in getting care
Due to the stipulation order in place, and substanital non-compliance, LPA Valerio conducted weekly visits to the facility. LPA observed staff constantly working with residents and daily tasks. According to Staff 1 (S), "I feel as though I am failing these residents because even though I am providing as much care as I am capable of, care staff have so much our plates that we can’t give them the care they deserve. It breaks my heart every day to see what these residents have to go through since there’s not enough hands on deck to give them everything they need."

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

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20230127145900
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: 07/19/2023
NARRATIVE
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Continued from LIC 9099 - A
Resident has wounds that are not properly care for
LPA received a picture of a leg and foot with a wound. The wound was black in color covered by thin clear bandage. The contents behind the bandage appeared to be seeping out of the bandage. When LPA received the photo, the photo was said to be of Resident 2 (R2). When LPA asked administrator Ernest about wounds, Administrator was not aware of any resident with a wound. According to S2, S2 did not know what kind of wound it was nor has S2 received any guidance or training regarding the wound. S2 stated they are unsure how long the wound has been there and it smells of rotting flesh. Due to the facility being closed on 04/12/23, LPA was unable to interview the resident or obtain more information regarding the wound.

Resident has not been moved in months due to Hoyer lift being broken
LPA Valerio observed the sit to steady located in Resident 3 (R3) room. LPA observed the brakes broken. LPA tried to locked it and it did not lock. LPA took a picture for reference. LPA asked facility staff to attempt to use to lift. According to staff S5, the lift is indeed inoperable. According to S6, S6 uses the lift but since it does not work properly S6 has to lift the patient with S6's arms and back. S6 states that R3 is transported daily and can, at most times, lift oneself with assistant of staff. According to an outside agency, Resident 4 also needs to a lift to move. According to S5, the lift that is broken is the personal property of R3.

Resident rental rates are illegally increased
On 01/12/23 LPA received current rent rate for Resident 4 (R4). On 03/09/23, LPA received a resident roster with current rental rates. When comparing the rates, LPA saw an increase of $235.45 from January to March of 2023. LPA obtained copies of R3's admission agreement and copies of invoices sent to the resident by the facility. Records revealed there was an increase of $285.00. According to facility representative, the increase was done on the payee's end. Due to the increase dollar amount, the payee stated the rental payment must be increased. According to the Sonora's facility representative, there was no new admission agreement because the rental increase was not initiated by them.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred. 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.  Exit interview was held and a copy of report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20230127145900
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: 07/19/2023
NARRATIVE
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32
Continues from LIC 9099
According to staff 3(S3), S3 admitted that showers did not get completed when S3 was on shift. Staff interviews show that staff did not neglect to complete showers on purpose and state there were lack of staff and time to do all tasks on one shift. According to a family interview, family stated they had to ask staff to shower their loved one. it was always initiated by the family.

Laundry is not being done in a timely manner resulting in residents wearing soiled clothing

According to staff interviews, S1, S2, and S3 confirmed that there is not enough time to do all the laundry. LPA Valerio observed the facility on 4 different visits where LPA observed 4 residents with soiled clothing, such as crumbs on shirt, holes in shirt or pants, stains on shirt or pants, or brown stains on pants.

Resident files are not completed

LPA reviewed 4 resident files. All files reviewed were observed to incomplete. Resident files did not have an updated LIC 602 Physicians report or an updated Services and Needs Appraisal form. According to S1, charting is sometimes left to be done at the end of the month because the company often refuses to approve overtime and in result, the staff leaves at their scheduled time so a lot of the charting ends up inaccurate. According to staff 4, S4 reviewed all medication records and found many files to be incomplete, without signatures, or with properly filled out by staff.

Facility does not provide enough staff to assist resident's needs

According to staff interviews, all staff interviews express that they do not have enough time to assist all the residents. As stated previously in this report, the facility is short staff to complete showering needs and resident laundry. According to S2, there were only 3 staff on shift to assist 53 residents. Out of 53 residents, almost half of the residents are located on the 1st floor, which is where residents with higher care needs reside. According to S5, S5 stated the administrator will say we are full staff, but there is never enough.

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

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20230127145900
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: 07/19/2023
NARRATIVE
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continued from LIC 9099

On 01/25/23, LPA observed 2 staff scheduled for the 1st floor, 1 staff scheduled for the 2nd and 3rd floor, and 1 medication technician for all residents. LPA was touring the facility when a resident came up to LPA to ask if LPA could help with another resident that had fallen out of a wheelchair. The resident stated the scream was soft so no one could hear the resident calling out for help. LPA looked around and could not find any staff due to staff being busy and on another floor. LPA went to the administrative office and notified office staff. The facility has a call light area for the 1st floor; however, their front desk staff is not in and there is no staff assigned to monitor the call lights. The facility was cited for insufficient staff to meet the needs of the residents. The facility was also cited on 03/03/23 for an insufficient number of staff to meet the needs of the residents. The facility failed to correct the deficiency on 03/06/23, 03/23/23, 03/28/23, and 04/02/23 visits.

Facility failed to notify incidents to CCL, Ombudsman, and Responsible Party / Facility failed to seek medical attention in a timely manner

An incident occurred on 01/25/23 where a resident (R1) had to be sent to the hospital for change of condition. Nine days prior to the resident being sent out, the resident had a fall on 01/21/23. The resident was not sent out to the hospital after the fall. According to interviews, a staff present during the fall filled out a SIR and put it on the Resident Care Coordinator's desk for review. CCL, the Ombudsman office, and Responsible Party was not notified of either incidents. According to medical records, R1 suffered a concussion from the fall.

Based on the above aforementioned information, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies 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. LPA requested Licensee Georgina to sign the copies and send back to LPA Valerio.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20230127145900
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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan... shall be developed by each facility...:(1)The licensee shall arrange, or assist in arranging, ... 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(a)(1) and send a written letter acknowledging understanding of regulation.
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Based on interviews, the licensee did not ensure residents recieved showers based on their shower schedule. This poses a potential health and safety risk to residents in care.
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Type B
08/02/2023
Section Cited
CCR
87307(a)(3)(F)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function...The following provisions shall apply: (F)Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not met as evidenced by:
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Licensee stated they will review section 87307(a)(3)(F) and send a written letter acknowledging understanding of regulation
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Based on interviews and observations, the licensee did not ensure residents received laundry services.
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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: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20230127145900
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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87506(a)
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87506 Resident Records (a)The 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(a) and send a written letter acknowledging understanding of regulation.
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Based on observations and records review, the licensee did not ensure resident files were maintain properly and kept up to date. This poses a potential health, safety, and personal rights risk to residents in care.
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Type B
08/02/2023
Section Cited
CCR
87705(c)(4)
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87705 Care of Persons with Dementia (c) Licensees... shall...ensure: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs...This requirement was not met as evidenced by:
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Licensee stated they will review section 87705(c)(4) and send a written letter acknowledging understanding of regulation.
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Based on interviews, records review, and observation, the licensee did not ensure there was an adequate number of direct care staff to suppport each resident. This poses a potential health, safety, and 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: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20230127145900
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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87211(a)
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5
6
7
87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... This requirement was not met as evidenced by:
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Licensee stated they will review section 87211(a) and send a written letter acknowledging understanding of regulation.
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Based on interviews and records review, the licensee did not ensure incidents were reported to CCL, the ombudsman, or responsibile party. This poses a potential health, safety, and personal rights risk to residents in care.
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Type B
08/02/2023
Section Cited
CCR
87465(a)(1)
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5
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7
87465Incidental 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 medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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3
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Licensee stated they will review section 87465(a)(1) and send a written letter acknowledging understanding of regulation.
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9
10
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12
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14
Based on interviews and records review, the licensee did not ensure medical attention was sought for a resident in care. This poses a potential health, safety, and personal rights 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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8