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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 11/22/2021
Date Signed: 12/09/2021 12:08:46 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
11/12/2021 and conducted by Evaluator Sarah Hurt
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211112103404
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:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Michael MaloneyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff not following COVID protocols.
Residents not receiving medications as prescribed
No care plan upon admission
Incomplete resident files
Staff not doing proper appraisals
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unnaounced on November 22, 2021 at 10:30 a.m. to conduct a complaint investigation on the above allegations. LPA met with Administrator Michael Maloney and explained the purpose of today's visit.
Regarding the allegation that residents are not receiving medications as prescribed. LPA reviewed Medication Administration Logs, and Centrally Stored Medication logs for several newly admitted residents. The Medication Administration Logs showed Resident 1 was not given a medication (Apixaban) used to prevent blood clots from the time admitted on 09/09/2021 to when he was finally prescibed the medication by a physician after being admitted to the hospital on 11/09/2021. The facility started giving Resident 1 the medication on 11/13/2021. Resident 2's 602 Physician's Report has no medication list attached despite mentioning Resident 2 needing assistance with medications, and specifically mentions an inhaler (albuterol) used PRN. Resident 2 was admitted to facility with no medications and no medications were entered into the Centrally Stored medication Logs since being admitted on 10/22/2021. Therefore, the allegation is deemed 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: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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-20211112103404
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: 11/22/2021
NARRATIVE
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Regarding the allegation the facility resident files are incomplete. LPA reviewed resident files for 4 newly admitted residents. The file for Resident 1 did not have a 602 Physician's Report despite resident being admitted on 09/09/2021. The file for Resident 2 had an incomplete 602 with no medication list attached. Therefore this allegation is SUBSTANTIATED.

Regarding the allegation the facility is not completing proper appraisals. LPA reviewed files for several newly admitted residents The resident files were missing 602's or had incomplete 602's in the files. Therefore this allegation is SUBSTANTIATED.

Regarding the allegation residents have no care plan upon admission. LPA reviewed several resident files, and there is no needs and services plan in facility resident files. Therefore this allegation is SUBSTANTIATED.

Regarding the allegation staff is not following COVID protocols. LPA reviewed several resident files, and also interviewed several staff members. The facility is not COVID testing newly recently admitted residents. Therefore this allegation is SUBSTANTIATED.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility staff and a copy of this report along with appeal rights was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20211112103404
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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited
CCR
87464
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Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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Licensee will conduct staff training from an outside source on assisting residents with medications and submit to 11/23/2021 POC date.
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This requirement has not been met as evidenced by:Based on record review, the licensee did not ensure residents were being assisted with taking medications as several were admitted into facility without prescribed medications, which poses an immediate health and safety risk to residents in care.

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Type A
11/22/2021
Section Cited
CCR
87458(a)
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87458 Medical Assessment (a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement has not been met as evidenced by:
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Licensee will submit completed resident 602's to LPA by POC date 11/23/2021.
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 Based on interviews, and records reviewed the licensee failed to include 602 Physician’s Reports in two resident files which poses an immediate risk to 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: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211112103404
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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
87467(a)(b)
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87467 Resident Participation in Decision making (a)Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.(b) At a minimum the written record shall include the date of the meeting, name of individuals who participated and their relationship to the resident, and the agreed-upon services to be provided to the resident.
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Licensee will conduct staff training from an outside source on needs and services plans. Licensee will also submit written needs and services plans for residents by 11/29/2021.
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This requirement has not been met as evidenced by: based on record review, the licensee failed to include needs and services plan in resident files which poses a potential risk to residents in care.
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Type B
11/23/2021
Section Cited
CCR
87506(a)
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87506 Resident Records ((a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement has not been met as evidenced by:
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Licensee will send proof of complete resident files to LPA, Licensee will also conduct staff training on complete resident files by POC date 11/23/2021.
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Based on record review the licensee does not have current physician’s reports, and needs and services plans in several resident files which poses an immediate risk to 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: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20211112103404
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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited
CCR
87458(b)(1)
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87458 Medical Assessment. (b)The medical assessment shall include, but not be limited to:(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
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Licensee will submit proof of understanding of regulation by 11/23/2021.
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This requirement has not been met as evidenced by: Based on interviews, and records reviewed the Licensee is not COVID testing residents prior to admission which poses an immediate health and safety risk to 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: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5