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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/14/2022
Date Signed: 03/14/2022 03:29:20 PM


Document Has Been Signed on 03/14/2022 03:29 PM - It Cannot Be Edited

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: 59DATE:
03/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator, Michael MaloneyTIME COMPLETED:
03:30 PM
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
Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced at 10:30 a.m. on March 14, 2022 to conduct a Case Management Health Check visit. LPA met with Administrator Michael Maloney and explained the purpose of today's visit.

LPA toured the facility kitchen, pantry, bathrooms, and resident rooms, and outdoor areas. LPA observed running warm water, electricity, and 7 day perishable food supply, and 2 days non perishable food supply. LPA observed residents complaining to facility staff their cable television was not working. Facility staff did confirm the cable was disrupted due to non payment. Facility staff did pay outstanding balance during the visit to re connect the cable television for residents. LPA spoke with several facility staff who all stated they are being paid accurately and on time.

LPA also spoke with three facility staff members related to an incident report received on February 18, 2022. The incident report reads on February 18,2022 at roughly 3:30 p.m., in the residents hall on first floor Resident 1 attacked and assaulted Resident 2 for walking into his room. Resident 2 was found on his bottom in front of Resident 1's room 119 with skin tears and lacerations to his face. LPA interviewed three facility staff and all stated Resident 1 continues to be a personal rights risk to other residents at the facility. Staff 1 stated she heard a scream recently coming from the dining area, and when she looked over she saw Resident 1 was grabbing Resident 3's hair and pulling on it. The facility was cited on 10/14/2022 for Personal Rights related to Resident 1 interfering in the care of Resident 3.

Continued on 9099C...
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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 3


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
VISIT DATE: 03/14/2022
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
Continued from 9099..

The three staff interviewed all stated Resident 2 pulls out his private area and urinates openly on a consistent basis inside the facility. The three staff interviewed also stated they have witnessed Resident 2 going in and out of other residents rooms regularly all hours of the day and night. The staff says they witness Resident 2 walking up to other residents in the dining hall and grabbing their ice cream and eating food from their plates
Resident 1 and Resident 2 remain a personal rights risks to other residents in care at the facility.

The following deficiency was 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: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/14/2022 03:29 PM - It Cannot Be Edited

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: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited

1
2
3
4
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.
8
9
10
11
12
13
14
The following requirement has not been met as evidenced by: Resident 2 continues to violate the Personal Rights of other residents in care. Resident 1 is also a Personal Rights to residents in care, which poses an immediate health, safety or personal rights risk to residents in care.
8
9
10
11
12
13
14

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: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3