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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:25:45 PM



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
04/14/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210414131341
FACILITY NAME:SONORA SENIOR LIVINGFACILITY NUMBER:
552700409
ADMINISTRATOR:KATRYNA HUNTFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Neglect/Lack of Supervision: Resident was sexually assaulted by another facility resident

Personal Rights: Resident was moved to a different bedroom without notifying responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sarah Hurt and Kevin Gould made an unannounced visit on this day to conclude a complaint investigation. LPAs met with Michael Maloney end explained the reason for the visit.
The initial 10-day visit was conducted on 4/16/2021. Through the course of the investigation, the Department reviewed incident reports regarding Resident 1 (R1) and Resident 2 (R2), reviewed physician’s report and needs and services plans, hospital records and conducted interviews of staff and other identified witnesses.

It was alleged that resident was sexually assaulted by another facility resident. On 4/14/2021, Resident Care Coordinator (RCC) Maranda Escobedo contacted CCL to report R1 sexually assaulted R2 on 4/13/2021. Per RCC Escobedo staff found R1 with their penis in R2’s mouth. Upon examination, R2 was noted to have bruising on both wrists showing possible force. 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. Report Continued on LIC 9099-C. Page 1 of 2.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20210414131341
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: 07/21/2021
NARRATIVE
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The plan states that R1 needs one to one supervision or ten-minute checks. Additionally, staff will keep R1 occupied with activities to keep R1 stimulated. Through interviews staff reported that R1 needed a higher level of care that the facility could not provide. The facility did higher additional staff to assist with providing supervision for R1, but when that staff was not present, the facility did not have staff to provide the supervision need for R1. Based on information provided through staff interviews and documentation the facility did not provide the supervision necessary to prevent R1 from assaulting R2, therefore the allegation was deemed SUBSTANTIATED.

It was alleged that resident was moved to a different bedroom without notifying responsible party. Through interviews it was noted that R1 and R2 were roommates. When staff observed R1 interacting inappropriately with R2, R2 was moved to another room down the hall. Witnesses reported that the responsible party was not aware of any incident between R1 and R2 prior to the incident that occurred on 4/13/2021. Based on information provided through interviews, the allegation that resident was moved without notifying responsible party was Substantiated.
The allegations noted have been deemed substantiated, meaning that there was a preponderance of evidence to prove that the allegations occurred as reported.

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.

Page 2 of 2.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210414131341
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: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited
CCR
87464(d)
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Basic Services; A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below,
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Licensee will provide written statemnt that facility will follow all physican orders pertaining to supervision and staff to resident ratios
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either directly or through outside resources.This regulation was not met as evidenced by:The license did not ensure that the facility met the needs of the resident. Based on documentation and interviews, R1 needed one to one supervision, but this supervision was not provided. This poses an immediate risk to the health and safety of residents in care
Immediate $500 civil penalty assessed.
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Type A
07/22/2021
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements; A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event;
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Licensee will review reporting requirements in Title 22 regulations. Facility will provide a written statement that administrator and managers have reviewed Reporting Requirements and a will ensure all incidents that meet the requiement will be reported to CCL, Ombusdperson and responsible party.
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This regulation was not met as evidence by: The licensee did not ensure that the facility provided a written report to the responsible party of incidents that threatened the welfare of any resident. Based on interviews R2’s responsible party was not notified of incidents between R1 and R2. This poses an immediate risk to the health and safety of residents 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/14/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210414131341

FACILITY NAME:SONORA SENIOR LIVINGFACILITY NUMBER:
552700409
ADMINISTRATOR:KATRYNA HUNTFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
3
4
5
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9
Facility is not following resident's diet orders.

Resident was left on the floor by staff for many hours.

Resident was locked in room by facility staff.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Sarah Hurt and Kevin Gould made an unannounced visit on this day to conclude a complaint investigation. LPAs met with Michael Maloney end explained the reason for the visit.
The initial 10-day visit was conducted on 4/16/2021. Through the course of the investigation, the Department reviewed incident reports regarding Resident 1 (R1) and Resident 2 (R2), reviewed physician’s report and needs and services plans, hospital records and conducted interviews of staff and other identified witnesses.
It was alleged that resident was locked in room by facility staff. it was reported that the previous Administrator stated that they lock the residents up to prevent them from engaging in inappropriate behaviors. Interviews were conducted with staff and residents Staff interviewed did report residents were locked in rooms. Most residents interviewed were unable to be a reliable historian due to medical reasons. One resident interviewed reported staff treated resident well and did not report being locked in room. It was unclear if the comment was made in jest or if staff did lock residents in their rooms. There was not a preponderance of evidence to prove or disprove that the allegation occurred therefore it was deemed UNSUBSTANTIATED.
Report continued on LIC 9099-C. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210414131341
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: 07/21/2021
NARRATIVE
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It was alleged that resident was left on the floor by staff for many hours. Resident 2 (R2) was hospitalized after being found on the floor and having difficulty breathing. It was reported that R2 had elevated levels due to being left on the floor for a long period of time. Medical records for R1 were reviewed and it was unclear if the elevated levels were due to being left on the floor or other medical reason. There was not a preponderance of evidence to prove or disprove that the incident occurred as reported, therefore it was deemed UNSUBSTANTIATED.

It was alleged that the facility is not following resident’s diet orders. Facility records were reviewed for R2. The physician’s report dated 1/11/2021 indicated that R2 does not have a special diet. The needs and services plan dated 3/30/2021 for R2 noted that R1 needed to have “Ensure” with meals. It is unclear if there was a physician’s order for R2 to have Ensure or if this was R2’s preference. Persons interviewed did not report R2 not receiving Ensure with meals. Based on record review and interviews there was not a preponderance of evidence to prove or disproved that the allegation occurred therefore it was deemed UNSUBSTANTIATED.

The allegations noted have been deemed unsubstantiated meaning that there was not a preponderance of evidence to prove or disprove that the allegations occurred as reported.

An exit interview was conducted with Michael Maloney and a copy of this report along with confidential names list was provided.

Page 2 of 2.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 5