552700409-10-13-2022-27-AS-LKIG-CKEUNH-20221021154355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 09/30/2022
Date Signed: 10/13/2022 03:29:47 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
09/30/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220930130144

FACILITY NAME:	SONORA SENIOR LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	MICHAEL MALONEY		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS: 63	DATE:	09/30/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Human Resources Manager, Wonda Wolski		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff is not safeguarding residents personal property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility September 30, 2022 at 01:30 p.m. to open a complaint on the above allegations. LPA Hurt met with facility Human Resources Manager Wonda Wolski and explained the purpose of the visit.
Regarding the allegation Staff is not safeguarding resident’s personal property. Based on interviews the facility staff did misplace Resident 1’s bedroom set. Resident Care Coordinator Maranda Escobedo stated Resident 1’s bed was placed into the facility shower/storage room after she was admitted to hospice services and required a hospital bed. Maranda stated when it was time for the bed to pulled out of storage after Resident 1 was discharged from hospice services it was no longer inside the facility shower/ storage room and she has no idea where the bed went from there. Resident Care Coordinator Maranda stated staff has searched everywhere for the bed frame and can not find it. The facility staff admits to misplacing Resident 1's bed frame, therefore, this allegation is SUBSTANTIATED.

Continued on 9099C..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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 3

Control Number 27-AS-20220930130144

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: 09/30/2022

NARRATIVE

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.....Continued from 9099

Regarding the allegation Uncleared adult working at the facility. Based on records reviewed the facility does have uncleared adults working at the facility. LPA reviewed Guardian Employee Roster and found five facility staff not background cleared working at the facility. Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 are all listed on the Guardian Roster as "In Process." LPA observed Staff 2, and Staff 5 present at the facility during today's visit. LPA Hurt spoke with Staff 6 who stated they were told by former Administrator Michael Maloney facility staff new hires do not need to be background cleared since the COVID 19 pandemic started. Staff 6 stated former Administrator Michael Maloney would only require new hires to go start the background clearance process and then allow them to begin working. Therefore, this allegation is SUBSTANTIATED.

A $500 Immediate Civil penalty is being issued for each uncleared adult working at the facility.

The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Human Resources Manager Wonda Wolski and copy of report left at facility

This report has been Amended.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220930130144

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: 09/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 10/14/2022 Section Cited CCR 87218(2)	1 2 3 4 5 6 7	87218(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153.The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a written plan to replace Resident 1's bed frame at current value and submit to LPA by 10/14/2022 POC date.
	8 9 10 11 12 13 14	Licensee misplaced bed frame for Resident 1, and failed to add Resident 1's bedroom set to LIC 621 Client/Resident Personal Property and Valuables form which poses a potential health, safety, or 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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

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