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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 08/26/2022
Date Signed: 08/29/2022 02:52:09 PM


Document Has Been Signed on 08/29/2022 02:52 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:
08/26/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee Gina Rodriguez, and Asok KumarTIME COMPLETED:
05:00 PM
NARRATIVE
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An Office Meeting was conducted on this day in the Sacramento South Regional Office via Microsoft Teams due to COVID 19 precautions. The purpose of this Office meeting was to follow up with the facility on recent complaint findings, the lack of Administrator at the facility, and facility nurse not being licensed. Present in the meeting was Licensing Program Manager (LPM) Stephenie Doub, Licensing Program Analyst (LPA) Sarah Hurt, Licensee Gina Rodriguez, Licensee Asok Kumar. Since the last meeting on May 3, 2022 a new complaint was Substantiated related to resident care, new complaints have been filed against the facility and several Type A deficiencies have been cited. The facility was cited on 07/19/2022 for Care and Supervision, Incidental Medical and Dental, and Reporting Requirements for the substantiated complaint related to lack of resident care. LPM Doub mentioned concerns that the facility nurse has yet to provide their Registered Nursing credentials despite being asked for it several times and continuing to present themselves as a nurse. As of now the facility is continuing to accrue civil penalties of $100 per day for not having a certified Administrator. The Licensee advised they are hiring a consulting company to assist with overseeing the facility, and hiring a new Administrator.

Issues discussed during the meeting were:
· Recent complaint findings
· Supervision issues
· False Claims
· Facility does not have an Administrator and continues to accrue civil penalties


The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Licensee Gina Rodriguez, and Asok Kumar. A copy of this report provided by email.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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 08/29/2022 02:52 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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited

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87207 False Claims .No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.The following requirement has not been met as evidenced by:
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Based on observation and records requested the facility nurse has never provided educational credentials, but still presents themselves to be a licensed nurse 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: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2