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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 07/19/2022
Date Signed: 07/21/2022 07:24:02 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220418083525
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:
07/19/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Resident Care Coordinator, Maranda EscobedoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility failed to seek medical attention in a timely manner resulting in resident being hospitalized
Facilty failed to provide supervision
Staff failed to report incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit on 07/19/2022 to deliver complaint findings on the above allegations. LPA met with Resident Care Coordinator Maranda Escobedo and explained the purpose of today's visit.

The initial 10-day visit was conducted on 4/18/2022. During the course of the investigation, the Department interviewed staff, reviewed medical records and reviewed facility documentation.

Regarding the allegation the facility failed to seek medical attention in a timely manner resulting in resident being hospitalized. Staff 1 provided text communication between herself and Staff 2 dated 3/25/2022, 3/30/2022, and 4/6/2022. The text communications included photographs of a sore and flaky dry skin, on R1’s lower left leg which was also red and appeared swollen.

Continued on 909C....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20220418083525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/19/2022
NARRATIVE
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Continued from 9099..


Based on interviews and records reviewed Resident 1 (R1) was seen in the Emergency Room (ER), at the local acute hospital on 4/6/2022 for swelling and a sore to their lower left leg. R1 was diagnosed with cellulitis and prescribed antibiotics. R1 was discharged on this same day. Resident 1’s responsible party was not aware of any issue to Resident 1’'s leg until the facility contacted her on 4/6/2022, to report Resident 1 was sent to the hospital.Multiple staff interviewed reported that Resident 1 should have received medical attention earlier than received. Based on interviews and records, there was a preponderance of evidence to prove that the facility failed to seek medical attention for resident in a timely manner, therefore this allegation was SUBSTANTIATED.


Regarding the allegation facility failed to provide supervision. Based on records reviewed and interviews conducted the facility failed to provide supervision of Resident 2 (R2) on several occasions. LPA reviewed text messages from Staff 1 to Staff 2 notifying them that R2 was in Resident 3’s room. The text stated, “Resident 2 is in Resident 3’s room is (their) supposed to not be in there”. Staff 2 responded “and I would monitor. Don’t kick out – it will cause behaviors for.” Based on R2 needs and services appraisal, R2 needed supervision to deter R@ from being aggressive to Resident 3 and other facility residents. Based on documentation noted, there was a preponderance of evidence to prove that the facility did not provide supervision needed per R2 appraisal, therefore this allegation was SUBSTANTIATED.



Continued on 9099...
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220418083525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/19/2022
NARRATIVE
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Continued from 9099C..


Regarding the allegation staff failed to report incident. Based on interviews and records reviewed the facility did not report this incident to Community Care Licensing. LPA reviewed the facility electronic file for April 2022, and emails sent from the facility from the same timeline. LPA did not find any incident reports documenting R1’s leg injury and hospitalization. Staff 2 was interviewed and denied that she reported the issue regarding R1’s leg to the Department of Social Services, Community Care Licensing Division (CCLD) nor did they notify R1’s responsible party when resident was first noted to have a change in condition. Staff 2 confirmed not submitting an incident report to CCLD stating they did not feel it rose to the level of needing to be reported. Based on information provided through interviews and facility documentation, there was a preponderance of evidence to prove that the facility did not report incident, therefore this allegation was SUBSTANTIATED.

The allegations noted have been substantiated, meaning that there was a preponderance of evidence to prove that the allegations did occur as alleged.

The following deficiencies are being cited today Per Title 22 Regulations.

Exit interview conducted with Resident Care Coordinator Maranda Escobedo and a copy of this report left at the facility along with appeals rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220418083525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by:
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Licesnee will conduct staff training on incidental medical and dental care by 07/20/2022 POC date.
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Based on interviews and records Resident 1 was not provided the proper medical attention for his leg injury which poses an immediate, health, safety or personal rights risk to residents in care.
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Type A
07/20/2022
Section Cited
HSC
1569.2(c)
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 Health and Safety Code section 1569.2(c) provides:(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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Licensee will conduct staff training on "Care and Supervision" and submit proof to LPA by 07/20/2022 POC date.
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Based on interviews and records reviewed Staff 1 was aware of the injury to Resident 1's leg, and did not provide proper medical treatment which poses an immediate health, safety, or personal rights ris 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: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220418083525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited
CCR
87211(a)(B)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The following requirement has not been met as evidenced by:
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Licensee will conduct staff training on reporting requirements and submit proof to LPA by POC date 08/02/2022.
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Based on records the facility did not report the injury or hospitalization of Resident 1 to CCL. LPA reviewed electronic facility file, and there was not incident report related to Resident 1's leg injury which poses a potential 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: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5