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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 07/28/2022
Date Signed: 07/29/2022 12:31:56 PM


Document Has Been Signed on 07/29/2022 12:31 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: 64DATE:
07/28/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Resident Care Coordinator, Maranda Escobedo TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility July 28, 2022 at 10:30 a.m. for a Case Management - Health Checks visit. LPA met with Resident Care Coordinator Maranda Escobedo 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 2 kitchen and dining staff cleaning the dining area from the lunch meal. LPA observed the residents eating the lunch meal of ham, peas, and roasted potatoes. LPA observed 3 Caregivers, and two medication technician present assisting residents. LPA observed hot running water, and electricity in the facility. LPA observed sufficient 7 day supply of non-perishable food, and 2 days perishable food supply.

LPA received an incident report documenting on Thursday July 21, 2022 Resident 1 left the facility and had not returned as of Friday July 22, 2022. The facility staff was not aware of Resident 1 being gone until the next morning despite him signing out the previous day. Resident 1 was gone overnight and was returned the next day. The facilities Plan of Operation states under "Admission Policies" "Sign in and Out Procedures" Residents and their Responsible Parties are required to notify of any planned overnight absences from the facility. Facility staff did not properly account for Resident 1.

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 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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Document Has Been Signed on 07/29/2022 12:31 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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2022
Section Cited

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87208 Plan of Operation(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: The following requirement has not been met as evidenced by:
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Resident 1 left the facility all night and staff did not notice he was gone until the following day 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: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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