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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 07/16/2021
Date Signed: 07/16/2021 04:04:48 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:
07/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Michael MaloneyTIME COMPLETED:
04:30 PM
NARRATIVE
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LPA Jason Lund conducted a case management visit on 7/16/21. LPA Lund met with Administrator Michael Maloney and explained the purpose of today's visit.

Community Care Licensing received an Unusual incident/ injury report on 7/9/21. The reports states on 7/8/2021 staff were looking for Resident (R1) and staff (S1) was doing room checks to find R1. S1 found R1 in Resident (R2) room on the bed. S1 told R1 that R1 needed to go to R1 room and R2 got upset and wanted a good night kiss from R1. R2 didn’t get the good night kiss and threatened to punch S1. S1 warned R2 not to hit anybody. R2 got upset and attempted to strike S1 and missed and hit R1 in the arm. R2 through another punch and struck S1 in the mouth. At which time S1 propelled (pushed) S2 who than fell and hitting the wall and table lamp.
S1 had to restrain R2 hands until additional staff could arrive. Staff gave first aid to R2 who had a contusion on left side of R2 face.

The review of the facility records the facility failed to report the incident on 7/8/2021 to the local ombudsman and police department. The facility has to fill out a SOC341 (Report of Suspected Dependent Adult/Elder Abuse) on any suspected elder abuse incident.

The review of the Unusual incident/ injury report on 7/9/2021 from the facility stated that S1 propelled (pushed) R2 into the wall and table lamp. R2 has the right to be free shall be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature.

Based on record reviewed, the following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Michael Maloney and a copy of this report was provided along with confidential names list and appeal rights.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited

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(c) An result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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This requirement was not met as evidenced by:
Based on record review, the licensee failed did not comply with the section cited above in filling out a SOC 341. which poses an immediate health and safety risk to resident in care.
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Type A
07/19/2021
Section Cited

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Personal Rights. Each resident shall be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature.
This requirement was not met as evidenced by:
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Based on record review, the licensee failed did not comply with the section cited above R2 has the right to be free shall be free from corporal or unusual punishment, or actions of a punitive nature which poses an immediate health and safety risk to resident 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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