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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 04/14/2022
Date Signed: 04/14/2022 07:59:34 PM


Document Has Been Signed on 04/14/2022 07:59 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:
04/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Michael MaloneyTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced to conduct a Case Management Health Checks visit at 10:30 a.m. on April 14, 2022. LPA met with Administrator Michael Maloney and explained the purpose for today's visit.

LPA received notification April 13, 2022 the facility was unable to place their Sysco food order because the invoices have not been paid. The Sysco food order would have been delivered on April 13, 2022 but has now been delayed to April 15, 2022 due to the issue with invoice non-payment.

LPA toured the facility kitchen and observed sufficient food supply. LPA observed the kitchen staff plating hot Salisbury steak, mashed potatoes, and vegetables. LPA also observed a warm dessert being served to residents along with hot coffee, and juice. LPA observed the facility has warm running water, and electricity.

The following deficiencies were cited per Title 22 Regulations an exit interview was conducted with facility staff Maranda Ecobedo and a copy of this report along with appeal rights 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: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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 2


Document Has Been Signed on 04/14/2022 07:59 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: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
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. This requirement has not been met as evidenced by:
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Licensee stated during office meeting on 04/12/2022 that all facility invoices are current and paid which is untrue as several Sysco invoices are unpaid which poses an immediate 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: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2