<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 12/23/2021
Date Signed: 01/11/2022 10:33:52 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
07/19/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210719170822
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: 61DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Michael MaloneyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not have sufficient staff to meet the needs of the residents
Licensee failed to provide adequate supervision
Licensee failed to seek medical care timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on 12/23/2021 at 09:30 a.m. to deliver findings on the above allegations. LPA met with Administrator Michael Maloney and explained the purpose for today’s visit.

Regarding the allegation Licensee failed to seek medical care timely. Based on record review and facility staff interviews Resident 1 was receiving consistent medical care by hospice services. LPA interviewed 3 facility staff members who all stated they have no reason to believe Resident 1 passed of anything besides medical conditions which she was receiving medical attention for regularly. LPA reviewed hospice documents dated 07/07/2021 outlining detailed hospice care for Resident 1 before her passing. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.








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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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 4
Control Number 27-AS-20210719170822
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: 12/23/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation Licensee failed to provide adequate supervision. Based on record review and interviews the death of Resident 1 was not related to lack of supervision by the facility staff. Resident 1’s cause of death was noted on death certificate as natural causes specific to a diagnosed medical condition with no other underlying cause. Resident 1 was receiving hospice care for a medical condition before passing. LPA reviewed documents stating Resident 1 was receiving hospice services. LPA also reviewed documents titled “Perimeter Checks” that is signed by facility staff acknowledging the outside perimeter was checked for any residents outside in the heat. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

    Regarding the allegation Licensee does not have sufficient staff to meet the needs of the residents. Based on interviews and record review, Resident 1 was on hospice care with adequate supervision from facility staff. LPA interviewed 3 facility staff members and all agree Resident 1 appears to have passed from natural causes due to a diagnosed medical condition with no other cause suspected. The death of Resident 1 does not appear to be in any way related to facility staffing issues. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

    LPA conducted an exit interview with Administrator Michael Maloney and a copy of this report was left at the facility.




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

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
07/19/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210719170822

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: 61DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Michael MaloneyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee failed to report the death or incident to CCL and Ombudsman
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on 12/23/2021 at 09:30 a.m. to deliver findings on the above allegations. LPA met with Administrator Michael Maloney and explained the purpose for today’s visit.
Regarding the allegation Licensee failed to report the death or incident to CCL and Ombudsman. Based on records reviewed Licensing was not notified on any incidents or death on 07/09/2021. LPA reviewed facility file and there was no death report on file. The death of Resident 1 was not reported properly through fax or phone to licensing. As a result of information obtained and the records reviewed the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Exit interview conducted with facility Administrator Michael Maloney and a copy of this report along with appeals rights left at the facility.
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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210719170822
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: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited
CCR
87211(a)(1)(A)
1
2
3
4
5
6
7
Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) 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; attending physician's name, findings, and treatment, if any; and disposition of the case.(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
1
2
3
4
5
6
7
Licensee will provide training to staff from outside source on reporting requirements. Licensee will send proof to LPA by 12/24/2021 POC date.
8
9
10
11
12
13
14
 This requirement has not been met as evidenced by: Based on records reviewed facility staff did not notify Licensing about the death of Resident 1.This poses an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4