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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:05:07 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
08/24/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210824081545
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: 50DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Michael MaloneyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
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5
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7
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9
Staff did not prevent resident from engaging in inappropriate behavior
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
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13
Licensing Program Analyst’s (LPA’s) Sarah Hurt and Ruth Wallace arrived at the facility unannounced to conduct a complaint investigation on the above allegation. LPA’s met with Administrator Michael Maloney and explained the purpose for the visit.


Regarding the allegations that staff did not prevent resident from engaging in inappropriate behavior. Based on LPA interviews with several staff Resident 1 has physically intervened in the care of other residents at the facility. Resident 1 intervenes and at times causes unecessary stress specifically to Resident 2 and Resident 3. The facility does not appear to have a plan in place to prevent resident from engaging in these behaviors. Based on this the complaint will be SUBSTANTIATED.




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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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 2
Control Number 27-AS-20210824081545
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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87705(a)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
1
2
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Administrator will have resident re evaluated. Administrator will send proof of this to LPA by POC date.
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9
10
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13
14
This regulation is not being met as evidenced LPA's observed a 602 dated 09/16/2020 more than one year old. This poses an immediate risk to residents in care.
8
9
10
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14
Type A
10/15/2021
Section Cited
CCR
87468(a)
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2
3
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5
6
7
87468 (a) Personal Rights. Residents in residential facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.
1
2
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Administrator will put a plan in place to deal with residents behavior. The staff will be made aware of and trained on this plan. Administrator will send proof of this to LPA by POC date.
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14
This regulation is not being met as evidenced by: Several staff interviewed stated resident 1 is interfering with the care of other residents. This poses an immediate risk to residents in care.
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9
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14
This is an amended document.
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: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2