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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 04/01/2021
Date Signed: 04/01/2021 01:47:53 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: DATE:
04/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Katryna HuntTIME COMPLETED:
11:00 AM
NARRATIVE
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On 4/1/21 Licensing Program Analyst (LPA) Kevin Gould conducted a tele-visit with Administrator Katryna Hunt to discuss observations LPA Gould made of medical records obtained from the facility on 3/15/21.

LPA Gould and Administrator discussed LPA Gould's review of R1 and R2's medical records from January 2021. LPA Gould discussed the facilities medication administration policies for controlled substances and narcotics. Administrator and Med-Aide Supervisor both confirmed all narcotic medications must be recorded in the resident's medication administration log and witnessed by another staff member who will sign the medication administration record indicating they witnessed another staff member.

LPA observed R1 and R2 both had medications identified as controlled substances or narcotics which were administered by S1 with no witness signature confirming the medication had been administered to R1 and R2.

Based on the information obtained during interview with Administrator, the following deficiencies are cited. See LIC 809-D.

A copy of this report and appeal rights have been mailed to the facility for signature.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
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: 04/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2021
Section Cited

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Incidental Medical and Dental Care: 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
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arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by staff S1 administering medications without following facility policy of ensuring narcotic medications are witnessed by another staff member which poses an immediate health and safety risk to resident in care.
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plan is being followed and medication is accurately inventoried.

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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2021
LIC809 (FAS) - (06/04)
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