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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 01/05/2021
Date Signed: 01/08/2021 03:32:26 PM



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
12/31/2020 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201231140427
FACILITY NAME:SONORA SENIOR LIVINGFACILITY NUMBER:
552700409
ADMINISTRATOR:KATRYNA HUNTFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: 63DATE:
01/05/2021
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Maranda Escobedo, RCCTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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1) roof has a leak
2) carpet has not been changed or cleaned and has stains throughout the facility
3) Fire drills not conducted in accordance with regulations.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint tele-inspection at Sonora Senior Living on 1/5/21 at 3:00pm to inform the licensee of complaint allegations mentioned above.

During this investigation LPA Gould interviewed S1 and RP (See confidential name list LIC-811 dated 1/5/21). S1 corroborated allegations made by RP. S1 confirmed the roof has leaks and has been an ongoing issue. S1 also corroborated allegations by RP that the facility has several carpet areas that are stained and need cleaning or replacement. S1 also could not provide evidence of fire drills conducted in accordance with regulations and states there have not been regular fire drills that they have participated in. LPA Gould recieved pictures from RP that corroborated allegations of dirty carpets.

Based on the interviews, information gathered, and documentation received the following deficiencies were cited. See LIC 9099-D. Exit interview was conducted and a copy of this report and appeal rights were mailed to the facility for signature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2021
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-20201231140427
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: 01/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2021
Section Cited
CCR
87705(l)(8)
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Care of Persons with Dementia: Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met as evidenced by. S1 was unable to provide LPA evidence of fire drills
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Facility will provide written plan of correction by 1/7/21 to ensure the facility will conduct fire drills as required every three month and will include at a minimum any staff that participate in direct care of residents. Afire drill will also be conducted by 1/8/21.
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being conducted as required every three months and not including all staff and poses an immediate health and safety risk to residents in care.
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Type B
01/18/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation: 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 and well-being of residents, employees and visitors. This regulation was not met as evidenced by:
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Facility will provide written documentation by 1/18/21 of efforts to have roof repaired. The facility will have 30 days to have the roof repaired to prevent future water leaks in the facility.
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S1 confirmed allegations from reporting party that the facility roof is leaking and in need of repair and poses a potential safety 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201231140427
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: 01/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation: 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 and well-being of residents, employees and visitors. This regulation was not met as evidenced by:
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Facility will provide written documentation by 1/18/21 of efforts to have carpet cleaning or replacement conducted. The facility will have 30 days to have the carpets cleaned or replaced as needed.
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S1 confirmed allegations from reporting party that the facility has several carpets in the facility in need of deep cleaning or replacement if carpets cannot be cleaned.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4