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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:11:09 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: 60DATE:
07/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator - MIchael MaloneyTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA's) Sarah Hurt and Ruth Wallace conducted an unannounced case management visit based on incident which occurred on July 3, 2021 for Resident (R1). LPA's explained the purpose of the visit to administrator.

The following documents were copied and obtained while at facility on July 8, 2021:
Tuolumne County Sheriff -
Incident Report dated 7/3/21
LIC 602A - Physician's Report 5/21/21
LIC 623 - Appraisal/Needs And Services Plan
LIC 624A - Death Report 7/3/21

The incident resulted in death and further investigation will be needed.

Exit interview with Administrator and a copy of this report was left at facility.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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