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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 03/16/2021
Date Signed: 03/16/2021 05:18:45 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: 57DATE:
03/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Administrator Katryna HuntTIME COMPLETED:
05:30 PM
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LPA Jason Lund conducted a case management visit on 3/16/21. LPA Lund met with Administrator, Katryna Hunt and explained the purpose of today's visit.

Community Care Licensing received a Unusual incident/ injury report on 3/12/21 stating that a resident (R1) had gotten out of the gated community. R1 was found a short time later and didn’t need any medical attention. R1's LIC602/physician's report dated 12/19/20 states R1 cannot leave the facility unassisted and has a diagnosis of Dementia.

Based on record reviewed, the following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Katryna Hunt and a copy of this report was provided along with confidential names list and appeal rights.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2021
Section Cited

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87705(c)(4) Care of Persons with Dresidents with dementia shall ensure an adequate number of direct care staff to support each resident’s needs. This requirement has not been met as evidenced by: ementia. Licensees who serve
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Based on record review, R1 left the facility unassisted on 3/12/21. R1's LIC602/physician's report dated 12/19/20 states R1 cannot leave the facility unassisted and has a diagnosis of Dementia which possess an immediate H&S risk to residents.
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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: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2021
LIC809 (FAS) - (06/04)
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