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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 09/23/2022
Date Signed: 09/27/2022 10:53:28 AM

Substantiated


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
09/16/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220916143502
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: 61DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Resident Care Coordinator, Maranda EscobedoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to assist with medical appointments
Staff failed to provide adequate supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility September 23, 2022 at 1:30 p.m. to deliver findings on the above allegations. LPA Hurt met with facility Resident Care Coordinator Maranda Escobedo and explained the purpose of the visit.

Regarding the allegation Facility failed to assist with medical appointments. Based on records reviewed Resident 1 had a doctor’s appointment on 06/03/2022 to receive a new 602 Physicians report. Resident 1 was given a Tuberculosis (TB) skin test during this visit. The medical clinic staff documents the facility would read the TB test and report the results back to the clinic. The results were never reported back to the clinic leaving the Physicians report incomplete. Resident 1 was taken back to the clinic on 08/30/2022 and given another TB skin test. The medical clinic staff documents the results were read by the facility and reported to their staff on 09/15/2022. Therefore, this complaint is SUBSTANTIATED.

Conitnued on 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 3
Control Number 27-AS-20220916143502
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: 09/23/2022
NARRATIVE
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...Continued from 9099...

Regarding the allegation Staff failed to provide adequate supervision Based on interviews and records reviewed Resident 1 continues to be physically aggressive towards other facility residents. Resident 1 physically attacked Resident 2 during a recent facility evacuation causing them to be hospitalized. Facility care notes document Resident 1 punched Resident 3 on September 8, 2022 and was in a physical altercation with Resident 4 on September 17, 2022. Therefore, this complaint is SUBSTANTIATED.

The following deficiencies cited today per Title 22 Regulations.

Exit interview conducted with Resident Care Coordinator Maranda Escobedo i 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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220916143502
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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) 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 arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by:
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Licensee will expedite Resident 1's 602 to ensure it is complete and provide proof to LPA by POC date of 09/24/2022.
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Resident 1 was not taken to have his TB test read or results were not reported to medical clinic timely which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
09/24/2022
Section Cited
HSC
1569.2(c)
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 Health and Safety Code section 1569.2(c) provides:(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The following requirement has not been met as evidenced by:
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Licensee will assign staff to supervise Resident 1 at all times and send proof to LPA by POC date 09/24/2022.
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Resident 1 continues to be physically aggresive towards other facility residents which poses an immediate 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: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3