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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 02/07/2022
Date Signed: 02/08/2022 09:07:45 AM

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: 61DATE:
02/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Michael MaloneyTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt made an unannounced visit to the facility 02/07/2022 at 10:00 a.m. to conduct a Case Management - Health and Safety visit. LPA met with Administrator Michael Maloney and explained the purpose for today's visit. The facility current census is 61, and 3 residents are currently on hospice care.

LPA toured the facility and observed residents in the kitchen area, first floors, and third floors of the facility. LPA toured the facility kitchen and pantry area. LPA spoke with four facility staff members, and 1 resident. LPA observed an outside food storage, and another cold food storage in the facility kitchen area. LPA observed insufficient food supply in all facility food storage areas.

LPA observed a closet with resident incontinent care supplies. LPA observed insufficient resident incontinent care supplies for residents size Large and Extra Large.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Michael Maloney 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: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2022
Section Cited

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87555(b)(26)General Food Service Requirements.The following food service requirements shall apply: Supplies of non perishable foods for a minimum of one week and perishable foods for a minumum of two days shall be maintained on the permises. This requirement is not being met as evidenced by
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Based on observations the facility does not have sufficient food supply which poses an immediate Health, safety or personal rights risk to residents in care.
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Type B
02/10/2022
Section Cited

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87307(a)(3)Personal Accomodations and Services(a (3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
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This requirement is not being met as evidenced by: Based on observations and records reviewed the facility does not have sufficient incontinent care supplies. LPA reviewed invoices from the incontinent care supply distributor showing a past due balance. The distributor is no longer delivering incontinent care supplies to the facility due to non payment which poses a potentiol health, safety or personal rights 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: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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