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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 06/15/2022
Date Signed: 06/16/2022 12:49:08 PM


Document Has Been Signed on 06/16/2022 12:49 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: 61DATE:
06/15/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Medication Technician ManagerTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility June 15, 2022 at 05:00 p.m. for a Case Management - Health Checks visit. LPA met with Medication Technician Manager Wonda Wolski 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. LPA observed 2 kitchen and dining staff. LPA observed kitchen staff preparing philly cheese steak sandwiches, with tater tots for the dinner meal. LPA observed kitchen staff preparing residents dinner trays. LPA observed 5 Caregivers and, one medication technician present assisting residents. LPA observed activities staff helping residents with board games. LPA observed hot running water, and electricity in the facility.

LPA reviewed 4 facility personnel files.

Staff 1's facility file does not have documentation of required 10 hours of initial training or First Aid/CPR certificate.

Staff 2's file does not have required educational certificate in personnel file.

Administrator Michael Maloney has resigned as of today close of business and is no longer the Administrator of the facility.

The following deficiencies cited today per Title 22 Regulations.

Exit interview conducted with Medication Technician Manager 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: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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


Document Has Been Signed on 06/16/2022 12:49 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: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited

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87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. The following requirement has not been met as evidenced by:
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Based on records reviewed Administrator Michael Maloney has resigned and this facility does not currently have an Administrator which poses an immediate health, welafre or personal rights risk to residents in care.
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Type A
06/16/2022
Section Cited

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87412 Personnel Records(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.(1)The following staff training and orientation shall be documented:(A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2). The following requirement has not been met as evidenced by:
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LPA reviewed file of facility staff 1 which did not have required CPR/first aid training, and did not have documentation of required training hours which poses an immediate risk to the health, safety, or personal rights of 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: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/16/2022 12:49 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: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited

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87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. The following requirement has not been met as evidenced by:
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Staff 1 does not have a first aid/CPR certificate in personnel file which poses an immediate risk to the health, welfare, or personal rights risk to residents in care
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Type B
06/29/2022
Section Cited

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87411 Personnel Requirements - General
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: The following requirement has not been met as evidenced by:
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Staff 2 does not have educational background certificate in personnel file which poses a potential threat to the 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: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3