552700409-7-3-2023-27-AS-KHOS-CU4NT7-20230726104417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 07/03/2023
Date Signed: 07/03/2023 02:51:27 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
12/30/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221230150803

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:	07/03/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Georgina Rodriguez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not report abuse to CCL, Local Ombudsman, or APS

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio, LPM Stephen Richardson, and LPA Arvin Villanueva met with Licensee Georgina Rodriguez via Microsoft Teams due to the facility being closed. The purpose of the meeting was to deliver complaint investigation findings.
On 12/30/22, the department was made aware of 2 physical abuse accidents involving Resident 1 (R1) and Resident 2 (R2). According to interviews with the Local Ombudsman Office, the facility did not report the incidents. According to the Office of the Public Guardian, the facility denied that the facility made a report to their office. According to file review and observations, the regional office did not receive notification of incidents or documentation reporting the incidents that occured on 05/14/22 and 12/13/22.

The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (Title 22, Division 6, Chapter 8), deficiences 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.

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: 07/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

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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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
12/30/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221230150803

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:	07/03/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Georgina Rodriguez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to neglect/lack of care and supervision, resident is physically abused by another resident

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 07/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

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-20221230150803

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: 07/03/2023

NARRATIVE

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Continued from LIC 9099 - A

According to an interview with R1, R1 reported someone had hit R1, but R1 could not remember the name. R1 remembers sitting at the dinning table when R2 walked up behind and hit R1 on the face. An interview with R2 was attempted but deemed unsuccessful due to cognitive state.

According to interviews with staff, staff reported R2 would hit other residents unprovoked. Staff could not tell when R2 was going to hit someone. R2 has a history of physical aggression and striking other clients in care.

Administrator Ernest Gibson reported that he was trying to evict R2, but he had no documentation. The previous person put in charge by the licensee, Maranda Escobedo, had submitted paperwork, but Ernest was unable to find copies. Ernest contacted Community Care Licensing (on 1/28/2023) who reported that he needed to resubmit the paperwork.

Staff deny receiving training on how to deal with aggressive clients. Staff would try to keep R2 out of residents' room, and away from residents R2 had previous issues with. For
combative residents, staff will try to redirect, do a change of face, or just leave the client alone.
On 9/2022, the facility sent communication to R2's doctor that R2 has had increased aggression.
The Resident Care Coordinator reported that R2’s care plan needed to be updated. According to records review, the most recent care plans are dated 9/2022, and 3/2023.

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, 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: 07/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221230150803

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: 07/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/10/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Licensee stated a review of section 87211(a)(1) will be conducted. Licensee to send a summary of regulations to show understanding and acknowledgment of the importance of reporting all unusual incidents.
	8 9 10 11 12 13 14	Based on records review, the licensee did not report incidents to licensing office, 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: 07/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

LIC9099 (FAS) - (06/04)

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