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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:33:32 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: DATE:
07/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Michael MaloneyTIME COMPLETED:
03:45 PM
NARRATIVE
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Case Management Deficiencies

Licensing Program Analysts (LPAs) Sarah Hurt and Kevin Gould made an unannounced visit on this day to conduct a case management visit regarding deficiencies observed. LPAs met with Michael Maloney end explained the reason for the visit.

On 4/13/2021, an incident occurred between Resident 1(R1) and Resident (R2) where R1 engaged in sexually aggressive behavior towards R2. R2 was found with the penis of R1 in their mouth. Both R1 and R2 have medical conditions which prevent them from providing consensual consent to participate in such interactions. R1’s Needs and Services Plan dated 1/28/2021 stated R1 was wandering around asking for sexual favors and attempting to enter into other residents’ rooms. The plan states that R1 needed one to one supervision or ten-minute checks. Through interviews staff reported that R1 needed a higher level of care that the facility could not provide. Multiple staff interviewed stated that the facility did not have staff to provide the supervision need for R1.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Michael Maloney and a copy of this report along with confidential names list and appeal rights was provided.

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

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited

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Acceptance and Retention Limitations. No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1).
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This regulation was not met as evidenced by:
The licensee retained a resident that required 24-hour intermediate care. Based on documentation R1 needed 1:1 supervision to manage identified behaviors, which is 24 hour intermediate care. This poses an immediate risk to residents in care.
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Type A
07/22/2021
Section Cited

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Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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This regulation was not met as evidenced by:The licensee did not ensure that there was adequate staff to support each resident’s needs. Based on information provided through interviews, staff reported not being able to meet R1’s needs due to lack of staffing. This poses an immediate risk to the health and safety of residents in care.
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Lcensee will provide written statement regaring incentives and steps the facility is taking to ensure staffing levels are appropriate to meet the needs of residents in care.
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: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2