552700409-7-25-2023-27-AS-KHOS-CU5JZP-20230727072951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 07/25/2023
Date Signed: 07/25/2023 12:18:34 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
03/07/2023 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20230307123847

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:	DATE:	07/25/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:			TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff did not ensure safety of resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio met with Licensee Georgina Rodriguez to discuss complaint investigation findings. The facility is closed, therefore, the meeting was conducted virtually. The Department has determined the following as it relates to the allegation: Facility staff did not ensure safety of resident's personal belongings

According to interviews, Responsible Party stated that Resident 1 (R1) moved out on February 2nd, 2023. According to facility records, R1 moved out on 02/02/2023. According to records review, the facility did not complete an inventory log for R1 when R1 moved in to the facility in 2021. R1's responsible party took photos of the belongings that the resident had and kept a personal list. LPA reviewed the photos for reference.

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: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

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-20230307123847

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: 07/25/2023

NARRATIVE

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Continued from LIC 9099 - C

R1 had moved out 02/03/2023. According to the Reporting Party, Administrator Ernest knew but did not tell the staff when R1 was scheduled to move out. When the RP showed up, not all of R1's items were in the room and only took what was there. Reporting Party made attempts after R1 moved out to get items back but received no calls or messages from the facility. According to the licensee, the facility representative/previous human resources manager should know more information on what happened to R1's belongings. According to interviews, previous Administrator Ernest was to work on obtaining the items for the resident. The responsible party provided a list of items that were lost. LPA reviewed the list, which included items such as blankets, clothing items, glasses, knee brace, clock, shoes, etc.

Per Health and Safety Code Section 1569.153, the facility is to have a theft and loss program and ensure resident belongings are safeguarded against theft or loss. Based on observations, interviews, and records review, the facility did not ensure to safeguard R1's belongings.

Based on the list provided, the R1 had 27 belongings that were not returned to R1 when R1 moved out. It is unknown where these items were placed. On 07/21/23, facility representative stated she found 3 items, however, this was 5 months after R1 had moved out. According to an estimate provided, the total current value of the items lost and due to R1 is $1,057.00.

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, deficiencies are being cited on LIC 9099 - D. Appeal Rights Provided. An exit interview was held, and a copy of the report was provided to Licensee Georgina.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230307123847

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: 07/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/04/2023 Section Cited CCR 87218	1 2 3 4 5 6 7	87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will reimburse R1 at the current value of all lost belongings. Licensee to send R1 a check via certified mail by POC due date. LPA to receive a copy of certified mail receipt and check.
	8 9 10 11 12 13 14	Based on observations, records review, and interviews, the licensee did not ensure R1's belongings were safeguarded and returned to R1. This poses a potential health, safety, and personal rights 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: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC9099 (FAS) - (06/04)

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