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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:45:47 PM


Document Has Been Signed on 06/02/2022 01:45 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: 63DATE:
06/02/2022
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 conducted an unannounced visit to the facility June 6, 2022 at 10:30 a.m.. for a Case Management - Health Checks visit. LPA met with Administrator Michael Maloney and explained the purpose of the visit.

LPA toured the facility in part to include lobby, kitchen, dining room, cafe, Fireside Lounge, Assisted Living (AL) area, bathrooms and common areas. Communal dining room is open.

LPA observed sufficient perishable and Non-perishable food supply. Menu offerings for lunch included homemade macaroni and cheese, salad, and chocolate chip cookies for dessert. LPA observed 3 kitchen and dining staff. LPA observed 5 Caregivers and, one medication technician. LPA observed activities staff helping residents with board games. LPA also observed housekeeping cleaning facility bathrooms. LPA observed hot running water, and electricity in the facility.

LPA is following up on an incident from May 17, 2022. LPA received a text on May 17, 2022 with photos of Resident 1's feet blistered. Resident 1 was outside on the deck with no shoes and his feet were burned from the hot pavement. Resident 1 was sent to the hospital for cleaning and evaluation. The facility staff was aware Resident 1 had no shoes on and was outside.

LPA observed a large approximately 8 inch hole on the back deck flooring that is accessible to residents at all times.

The following deficiencies are being cited during this visit per the California Code of Regulations Title 22.

Exit interview conducted with Facility staff Wonda Wolski and a copy of this report along with appeals rights left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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 06/02/2022 01:45 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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited

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87464 (c)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. The following requirement has not been met as evidenced by:
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Resident 1 was left outside with no shoes and his feet were burned by the hot pavement which poses an immediate risk to the health, safety or personal rights of residents in care.
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Type A
06/03/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The following requirement has not been met as evidenced by:
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LPA observed an 8 inch hole in balcony flooring which poses an immediate health, safety or personal risks 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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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