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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/12/2021
Date Signed: 03/12/2021 06:04:04 PM

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:KATRYNA HUNTFACILITY TYPE:
740
ADDRESS:18760 CHABROULLIAN LNTELEPHONE:
(209) 984-5124
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:90CENSUS: 58DATE:
03/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Maranda Escobedo, RCC/RNTIME COMPLETED:
05:00 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 Manager (LPM) Stephenie Doub contacted the facility on this day to conduct a Case Management visit via telephone due to COVID-19 and pre-cautionary measures. LPM spoke with Resident Care Coordinator (RCC) Maranda Escobedo and discussed the purpose of the call.

During review of Resident 1's (R1) medical records, it was observed that R1 returned to the facility after being at a skilled nursing facility for two months on 4/15/2020. On 4/17/2020, the Home Heath Agency completed an assessment of R1 and found that R1 had an unstageable pressure injury on the left heel and a stage 3 pressure injury on both great toes. R1 began receiving Hospice services on 5/20/2020. The facility retained R1 at the facility with an unstageable wound and a stage 3 pressure injury which is a prohibited health condition without an exception prior to R1 beginning Hospice services. Facility records for R1 were reviewed including the Appraisal/Needs and Services Plan which was dated 5/15/2020. Per the plan, R1 was to be checked on hourly to remind R1 to use the restroom. Facility staff was interviewed along with the Administrator. All staff interviewed reported that R1 was checked on every 2 to 3 hours.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with RCC Escobedo and a copy of this report was provided along with confidential names list and appeal rights via email. An electronic response confirms receipt of these documents.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2021
Section Cited

1
2
3
4
5
6
7
Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
8
9
10
11
12
13
14
This regulation was not met as evidence by:
The licensee did not ensure that persons having a stage 3 and 4 pressure injuries were not retained in the facility. Based on documentation, the R1 had stage 3 and unstageable pressure injuries. This poses an immediate risk to residents in care.
8
9
10
11
12
13
14
***Civil penalty of $500 asssessed.
Type A
03/13/2021
Section Cited

1
2
3
4
5
6
7
Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...
This regulation was not met as evidence by:
8
9
10
11
12
13
14
The licensee did not ensure that the facility met the resident's needs. Based on information provided through documentation and interviews, staff were not following the residents plan of care.
This poses an immediate risk to residents in care.
8
9
10
11
12
13
14
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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2021
LIC809 (FAS) - (06/04)
Page: 2 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2021
Section Cited

1
2
3
4
5
6
7
Administrator - Qualifications and Duties The administrator shall...Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents'... Reappraisal...
8
9
10
11
12
13
14
This regulation was not met as evidenced by:
The licensee did not ensure that the administrator provided the resident with services identified in the resident's reappraisal. Based on interviews, the AD did not know R1 was to be checked hourly.
This poses an immediate risk to residents.
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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3