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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 03/12/2021
Date Signed: 03/12/2021 05:56:34 PM



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
06/08/2020 and conducted by Evaluator Stephenie Doub
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200608094418
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: 58DATE:
03/12/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Maranda Escobedo, RCC/RNTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Resident sustained multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Stephenie Doub contacted the facility on this day to conclued a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPM spoke with Resident Care Coordinator (RCC) Maranda Escobedo and discussed the purpose of the call and the elements of the allegations.

The initial 10-day visit was conducted on 6/9/20 where LPM toured the facility and observed residents in common areas. LPM also observed the room of Resident 1 (R1). LPM requested the staff schedule. staff roster with contact information, resident roster, physician's report for R1 and preappraisal for R1, and list of residents receiving hospice care services with agency contact information. The department also conducted interviews with staff and identified withness and reviewed R1's hospice and home health care notes.
Based on documentation, R1 returned to the facility after being at a skilled nursing facility for two months on 4/15/2020. On 4/17/2020, Home Heath Agency completed an assessment of R1 and found that R1 (cont. on page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
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 6
Control Number 27-AS-20200608094418
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: 03/12/2021
NARRATIVE
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(cont. from page 1) had an unstageable injury on the left heel and a stage 3 pressure injury on both great toes. On 5/6/2020, home health notes report observing two stage 2 pressure injuries on the buttocks. It was unclear if the stage 3 pressure injury and unstageable injury were acquired at the skilled nursing facility and discovered two days later. Also the other pressure injuries were noted to be no greater than a Stage 2 which is allowed per regulations. Hospice notes also report that the Stage 2 injuries were healing or healed. There was not a preponderance of evidence to prove or disprove that the resident sustained multiple injuries while in care, therefore the allegation was deemed UNSUBSTANTIATED.

An exit interview was conducted with RCC Escobedo and a copy of this report along with confidential names list was provided via email. A confirmation read receipt confirms receipt of these documents.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
06/08/2020 and conducted by Evaluator Stephenie Doub
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200608094418

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: 58DATE:
03/12/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Maranda Escobedo, RCC/RNTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Facility staff is not following resident's wound care plan
Facility staff left resident in soiled clothes for an extended period of time
Facility staff did not ensure that resident had bed linens
Facility is not kept clean
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Stephenie Doub contacted the facility on this day to conclued a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPM spoke with Resident Care Coordinator (RCC) Maranda Escobedo and discussed the purpose of the call and the elements of the allegations.

The initial 10-day visit was conducted on 6/9/20 where LPM toured the facility and observed residents in common areas. LPM also observed the room of Resident 1 (R1). LPM requested the staff schedule. staff roster with contact information, resident roster, physician's report for R1 and preappraisal for R1, and list of residents receiving hospice care services with agency contact information. The department also conducted interviews with staff and identified withness and reviewed R1's hospice and home health care notes.
It was alleged that the facility staff was not following the residents wound care plans. Interviews were conducted with Hospice nurse and facility staff. Per Hospice nurse, there was not a written care plan for R1 but the staff were instructed to monitor the dressing and call hospice if there were any concerns. (cont. pg 4)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20200608094418
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: 03/12/2021
NARRATIVE
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(cont. from page 3) Per staff interviews, staff noted R1's had visible drainage and a foul odor on 5/30/2020 and 5/31/2020. Staff also reported seeing maggots in the wound of R1 on morning of 6/2/2020. Hospice records do not show any calls from the facility to Hospice reporting the changes to R1's wounds. Based on information provided through interviews and documentation the allegation that staff did follow the resident's wound care plan was SUBSTANTIATED.

It was alleged that the Facility staff left resident in soiled clothes for an extended period of time; did not ensure that resident had bed linens; and facility is not kept clean. Per Hospice care notes, R1 was found on multiple occasions soaked in urine, without any sheets on their bed and bedroom in disarray. Per documentation, R1's bedroom was found with bedside urinal filled with urine, clothes on floor, foul odor and walker out of reach for R1 to access. Based on information provided through documentation, the allegations of resident being left in soiled clothes, no bed lines and facility not kept clean were SUBSTANTIATED.

This agency investigated the allegations noted and found the allegations to be substantiated meaning that there was a preponderance of evidence to prove that the allegations occurred as reported.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with RCC Escobedo and a copy of this report was provided along with appeal rights via email. An electronic response confirms receipt of these documents.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20200608094418
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: 03/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2021
Section Cited
CCR
87633(b)(4)
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Hospice Care of Teminall Ill Residents. A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following...facility staff duties; record keeping; and communication with the hospice agency...
This regulation was not met as evidece by:
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Facility has hired a full time staff responsible for communicating with Hospice. Facility will provide a copy of procedures for ensuring communication with Hospice agency. This will be provided to CCL by the POC date of 3/13/2021.
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The Licensee did not ensure that a written hospice plan was maintain at the facility that included communication with the hospice agency. Based on interviews, the facility did not contact hospice when there was a change in resident's condition. This poses an immediate risk to residents in care.
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Type A
03/13/2021
Section Cited
CCR
87625(b)(3)
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Managed Incontinence. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Facility will provide training to all staff regarding incontinent plans for each resident to ensure staff aware of individual plan of each resident. Proof of training will be provided to CCL by the POC date of 3/13/2021.
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This regulation was not met as evidence by:
The licensee did not ensure that the resident was kept clean and dry. Based on documentation, the resident was found multiple times in urine soaked clothes. This poses an immediate risk to the health and safety of 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20200608094418
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: 03/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2021
Section Cited
CCR
87307(a)(3)(C)
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Personal Accommodations and Services. Equipment and supplies necessary for personal care...shall be readily available to each resident...the licensee shall assure provision of:(c) Clean linen, bedspreads, top bed sheets, bottom bed sheets, pillow cases and mattress pads...
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Facility will provide training to staff regarding room checks. POC will be provided to CCL by 3/15/2021.
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This regulation was not met as evidence by:
The licensee did not ensure that a provision of clean linens was available to each resident. Based on documentation the resident was observed with no sheets on their bed. This poses a potential risk to residents in care.
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Type B
03/15/2021
Section Cited
CCR
873039(a)
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Maintenance and Operation.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.
This regulation was not met as evidence by:
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Facility will create checklitst of items to check when checking on residents. POC will be provided to CCL by 3/15/2021.
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The licensee did not ensure that the facilty was clean at all times. Based on documentation, the residents room was found with bedside urinal filled with urine, clothes on floor, foul odor and walker out of reach for R1 to access. This poses a potential 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6