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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/22/2022
Date Signed: 03/22/2022 05:15:05 PM


Document Has Been Signed on 03/22/2022 05:15 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:
03/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Michael MaloneyTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility to conduct a Case Management (Health Checks) visit. LPA met with Administrator Michael Maloney and explained the purpose for today's visit.

LPA observed running water and working electricity in the building. LPA observed 7-day non-perishable food supply, and 2 days perishable food supply.

LPA reviewed emails between facility staff, and Cysco food supplier. In emails dated March 22, 2022 from Cysco food supplier to the facility reads “your order was not processed, possibly due to outstanding invoices, please contact your SC."

Another email dated March 15, 2022 reads "our records indicate your account has an outstanding balance that is past the due date based on the payment terms. This notice is trying to resolve this issue to avoid any
disruption of service. Total Balance $5,550.27."

LPA reviewed an invoice from the facility work comp insurance provider State Compensation Insurance Fund. The invoice reads "Insurance Cancellation Effective 04/01/2022 @ 12:01 A.M. Reason: Failure to pay premium when due. Amount $10,413.08"


Continued on 9099C...
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 03/22/2022
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Continued on 9099..

LPA reviewed facility Centrally Stored Medication Logs, and Medication Administration Records to ensure residents have sufficient medication supply.

Resident 1 did not have Olanzapine from 02/03/2022 to current. Resident 1 also did not have Verapamil 240mg 02/09/2022 to current.

Resident 2 has no medication entered the Centrally Stored Medication Log. Resident 2 does have Alprazalom .25 mg and Gabapentin 300mg, but has never been given any meds since she started living at the facility because she does not have all medications listed on medication list. Resident 2 was admitted to the facility with no medication and her family brought the two medications listed after she had already been living at the facility. Resident 2's 602 states she can NOT manage medications on her own.

Resident 3 was to be transported to a medical appointment March 22, 2022. Resident 2 is considered full assist so the dial a ride arranged for her could not safely transport Resident 3 to her appointment. The facilities Plan of Operation states “ Where the family or responsible party is unavailable, a facility staff person will escort resident to all medical and dental appointments.”

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility Resident Care Coordinator 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: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2022 05:15 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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited

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87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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This requirement has not been met as evidenced by: Based on records reviewed and LPA interviews the the facility was behind on payments to vendors including, Sysco (food distributor), and workmans comp insurance which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
03/23/2022
Section Cited

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87464 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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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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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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/22/2022 05:15 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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/29/2022
Section Cited

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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
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The following requirements have not been met as evidenced by: The facility is not accompanying or transporting residents to medical appointments as needed which poses a potential health, safety or personal rights violation 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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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