<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 08/24/2022
Date Signed: 08/26/2022 05:24:06 PM


Document Has Been Signed on 08/26/2022 05:24 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: 60DATE:
08/24/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Resident Care Coordinator, Maranda EscobedoTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility August 24, 2022 at 02:30 p.m. for a Case Management - Health Checks visit. LPA Hurt met with facility Human Resources Manager, Wonda Wolski and explained the purpose of the visit.

LPA toured the facility in part to include lobby, kitchen, dining room, Fireside Lounge, Assisted Living (AL) area, bathrooms and common areas.

LPA observed sufficient perishable and Non-perishable food supply. LPA observed 6 Caregivers, and one medication technician present assisting residents. LPA observed residents watching a movie in the fireside lounge. LPA observed the kitchen staff unloading the facility SYSCO food order. LPA observed three activities staff assisting residents playing bingo in the main lobby. LPA observed hot running water, and electricity in the facility.

LPA observed Resident 1's room to be extremely cluttered, with a strong odor coming out of it. Resident 1's room also smells like bleach and is so cluttered and messy it appears to be a health hazard.

LPA spoke with two facility residents in room 108. The residents were chatting and both appeared to be doing well.

The following deficiencies cited today per Title 22 Regulations.

Exit interview conducted with Human Resources Manager Wanda 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: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 2


Document Has Been Signed on 08/26/2022 05:24 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: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2022
Section Cited

1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.The following requirement has not been met as evidenced by:
8
9
10
11
12
13
14
LPA observed resident 1's bedroom to be extremely cluttered and has a foul odor coming from it which poses a potential risk to the health, safety, or personal rights of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2