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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 03:26:04 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
02/10/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230210112852
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):
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Facility is hazardous
Facility's activity list is inaccurate
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio contacted Licensee Georgina Rodriguez 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.

Facility is hazardous

LPA Valerio conducted a site visit on 02/17/23 and 03/28/23. During the visits, pictures of the physical plant were obtained for future reference. On the second floor patio, there is a walk way with a "gardening" area. A person standing in this area would be able to see the 3rd floor patio if they were to look upwards. Under the railing a person will be able to see exposed wood paneling, which appears that the wood is rotting or has been damage. The wood is not solid, there are pieces of the wood falling off and it appears to be in strands, similar to a string cheese texture.
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 5
Control Number 27-AS-20230210112852
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 the 1st floor (bottom level), there is a facility deck. This deck is not closed off to residents in care. The facility deck had pieces of the floor (rubber roofing material) ripped from the wood, which left the parts of the wood deck exposed. It appears that a previous storm caused the material to separate from the deck. LPA took pictures of the floor in the common area and facility outside deck for future reference. The wind caused the pieces to fly toward the right side of the deck near one of the exit doorways. LPA observed the facility to have areas where the roof is leaking. Areas of leaking were observed in the receptionist office and the door way by the kitchen hallway. Pictures were obtained for reference. According to staff, when it rains, the roof leaks. There was evidence of the leak from the water buckets placed under the leak and a large whole in the ceiling. These observations pose a potential health, safety, and personal rights risk to residents in care.

Facility's activity list is inaccurate

According to Administrator Ernest, the facility did not have an Activity Director until November of 2022. The Activity Director was hired as a full-time position to ensure activities are provided to residents in care. An activity assistant was hired in January of 2023, however, the assistant works part-time as a caregiver and part-time as an activity assistant. According to a staff interview, the assistant was pulled to be a caregiver due to the facility being short staff. According to a staff interview (S2), S2 schedule is Monday - Friday. S2 tries S2's best to ensure there are activities everyday, even the days S2 is not on shift .On weekends, there are not as many activities because they are short staff. S2 schedules staff to have the movies and popcorn during some of the days and residents love it. According to records review, the facility had posted a month's worth of activities on the wall. LPA observed the facility. On 02/17/23, the facility was observed to conducting activities with residents. On 03/23/23, LPA Valerio and LPM Richardson observed no activities being conducted for residents in care. LPA reviewed facility files from 12/01/22 - 02/15/23. LPA observed sign in sheets written by the Activity Director/Assistant. Dates of no activity sign in sheets are: 12/08, 12/09, 12/10, 12/11, 12/17, 12/18, 12/21 - 01/18, 01/21, 01/22, 01/28, 01/29, 02/04, 02/11, and 02/12. LPA observed a pattern of when the Activity Director was not on shift, no activities were being conducted.

Per California Code of Regulations - Title 22, deficiencies are being cited on LIC 9099 - D. Failure to correct deficiencies may result in civil penalties. An exit interview held, appeal rights provided, and a copy of the report will be provided. Licensee to review, sign, and return back to LPA via email.
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: 2 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
02/10/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230210112852

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):
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Resident sustained injuries while in care
Facility did not give families the correct contact information for licensing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio contacted Licensee Georgina Rodriguez 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.

Resident sustained injuries while in care

LPA interviewed Administrator Ernest. According to the interview, Administrator Ernest could not recall any residents that may have sustain injuries in December of 2022. LPA was provided a copy of Resident 1 (R1) files due to Reporting Party stating the family member moved out in December of 2022. Per Administrator, R1 was the only resident to move out during that time frame. Records did not disclose any information where R1 was involved in an incident.

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: 3 of 5
Control Number 27-AS-20230210112852
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

LPA reviewed incident reports submitted to the Department. Incident reports and previous follow up regarding incidents did not indicate that injuries were caused due to neglect or lack of supervision from the facility.

Facility did not give families the correct contact information for licensing

The above allegation is in regards to the May 2022 letter that was allegedly sent out by the facility. The letter sent in May of 2022 was to disclose that the facility was going to be listed for sale. LPA attempted to obtain copies from the reporting party and the facility. No contact information was provided by the reporting party and Administrator Ernest was not present in May of 2022. LPA checked facility records maintained at the facility and discovered that the facility did not have a copy of the alleged letter sent to residents and responsible parties.

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.  An exit interview was held and a copy of report will be provided. Licensee Georgina to review, sign, and return a copy 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: 4 of 5
Control Number 27-AS-20230210112852
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
87303(a)
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8730 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not as evidenced by:
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Licensee stated they will review section 87303 (a) and send a written letter acknowledging understanding of regulation.
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Based on observations and interviews, the licensee did not ensure the physical plant of the facility was maintained in good repair. 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
87219(a)
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87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement was not met as evidenced by:
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Licensee stated they will review section 87219 (a) and send a written letter acknowledging understanding of regulation.
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Based on observations, interviews, and records review, the licensee did not ensure activities were conducted when the activity director was off shift. 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: 5 of 5