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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 07/25/2023
Date Signed: 07/25/2023 12:16:14 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
03/15/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230315085937
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:
07/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Georgina RodriguezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff do not report incidents involving resident as required.
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: Staff do not report incidents involving resident as required

According to the reporting party (RP), there were multiple times were resident 1 (R1) had incidents happen and RO would not find out until later, never, or until RP received a bill for hospital services. RP stated staff would be reluctant to provide information and would not return RP call. According to a staff interview, staff were to complete an unsual incident report and notify responsible parties if the resident was sent out. Staff reported that most of the time it would be the Resident Care Coordinator to talk to the families due to staff not having enough time.

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: 07/25/2023
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)
Page: 1 of 5
Control Number 27-AS-20230315085937
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

Documents were obtained from the facility on 03/16/2023. Documents included unusual incident reports that were not submitted to licensing. The reports were found on the Resident Care Coordinator's and Administrator's desk. Incident reports had incidents involving resident to resident physical altercations, unwitnessed falls, and medical emergencies. Based on review of the incident reports, there was no signature from management stating they reviewed the report. Based on review of the Regional Office Electronic Facility File, the Regional Office did not receive such copies in the fax.

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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 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)
Page: 2 of 5
Control Number 27-AS-20230315085937
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
87211(a)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:... This requirement was not met as evidenced by:
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Licensee stated she will review section 87211(a) and provide LPA a written statement acknowleding the importance of sending incident reports and summarize her understanding of the regulation. Licensee to provide statement by POC due date.
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Based on observations and records review, the licensee did not ensure incidents were reporting to the licensing agency or responsible parties. This poses a potential health, safety, and personal rights risks 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: 07/25/2023
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)
Page: 3 of 5
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
03/15/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230315085937

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:
07/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Georgina RodriguezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Lack of supervision by staff resulting in resident sustaining several unwitnessed falls.
Lack of supervision by staff resulting in resident sustaining several unexplained injuries, including arm fracture.
Staff do not provide a safe environment for residents in care.
Staff do not adequately monitor the behavior of resident(s) in care.
Staff do not respond to requests for communication about resident(s) in a timely manner.
Resident was not accorded privacy.
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.

According to records review, the Regional Office obtained 10 unusual incident reports on 03/16/23. 7 out of 10 unusual incident reports were unwitnessed falls. LPA reviewed staff schedules for January 2023 - March 2023. Staff schedules show that the facility had 2 to 3 caregivers scheduled to work during AM, PM, or NOC shift. There were at times 3 caregivers and 1 medication technician scheduled. Although the staff schedules reflect this information, according to previous interviews from staff regarding another complaint investigation, staff schedules are sometimes not accurate. Due to the facilty being closed, LPA was unable to interview residents or additional staff.

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: 07/25/2023
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)
Page: 4 of 5
Control Number 27-AS-20230315085937
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 - A

According to the Reporting Party (RP), Resident 1 (R1) sustained unexplained injuries, including an arm fracture. According to RP, all the incidents RP was aware of were all unwitnessed. LPA reviewed facility records for R1. According to medical records, R1 went to the hospital in August of 2022. Medical Discharge paper work dated 08/23/2022 stated R1 was in the hospital for 5 days due to having a fall from standing height and sustained an injury to the right shoulder. R1 went to urgent care and was noted to have a fracture of the proximal humerus and was treated with a sling and pain medication. R1 was provided a follow-up care appointment. It is unclear if the fall occurred due to the neglect of staff or due to an accidental fall.

LPA reviewed additional medical records, dated 03/12/23, which stated R1 was seen in the hospital due to fall. X-ray did not find any injuries and only indicated bruising. According to the RP, the facility did not report the incidents to the RP. There were other instances where the RP was notified later or had to question staff.

The facility had a receptionist until January of 2023. The receptionist would answer incoming calls, call responsible parties, notify staff of call lights, and complete administrative tasks. When the receptionist left, other administrative staff, such as the Administrator and Human Resources manager, would cover the receptionist desk. During LPAs weekly visits, it was observed that the receptionist desk would be vacant most times.

LPA reviewed 1 incident report that discussed an incident between 3 residents, which did not include Resident 1. The incident report stated that two residents were naked and in a bed in front of the other resident. According to staff, the residents were found by staff and separated. Residents were assessed and no injuries reported. According to the SIR, the two residents did this frequently but were asked to be mindful of the roommate.

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. 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 given to Licensee Georgina Rodriguez.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 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)
Page: 5 of 5