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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:23:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
552700409
ADMINISTRATOR:MICHAEL MALONEYFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: 62DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Michael MaloneyTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst's Sarah Hurt and Albert Johnson arrived at the facility at 10:30am on Friday June 25,2021 for an unannounced required yearly inspection. LPA's met with Administrator Michael Maloney and informed him of the reason for our visit today. There current census is 62 residents and 5 are currently receiving hospice care. LPA's toured the facility, and also spoke with a few residents.

. LPA'S inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. During the facility tour LPA's observed adequate lighting, adequate furniture in the residents rooms. During facility tour LPA's observed elevator permit expired on June 26,2020. LPA's smelled malodorous odors on the second floor.

Fire extinguishers expire 02/08/2022. The facility has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 118.6 F degrees. First Aid kit is on site and complete. Toxins are locked.

This facility is operating within the scope of their license. LPA's reviewed 10 resident files and 5 staff files. First Aid and CPR training for all staff was current and staff has current required training hours.

The following deficiency's are being cited please refer to attached 809D.

Exit interview conducted with Administrator and copy of report left at facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This requirement has not been met as evidenced by: LPA's smelled incontinence odors on carpet throughout facility. LPA's also observed elevator inspection certificate expired June 26, 2020.This is an immediate safety risk to the residents in care.
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Additionally the facility will have the carpet cleaned or a plan to have carpet cleaned and submit plan or invoice to LPA by fax or email by the POC date.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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