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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 09/30/2022
Date Signed: 10/04/2022 07:05:59 PM


Document Has Been Signed on 10/04/2022 07:05 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:
09/30/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Human Resources Manager, Wonda WolskiTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility September 30, 2022 at 10:30 a.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 5 Caregivers, and one medication technician present assisting residents. LPA observed residents watching a movie in the fireside lounge. LPA observed the kitchen staff making fish and chips with coleslaw for the residents dinner meal. LPA observed facility staff cleaning the kitchen from the lunch meal. LPA observed hot running water, and electricity in the facility.

LPA received an incident report dated 09/27/2022 and faxed to Licensing on 09/29/2022 documenting water coming from the walls inside the second floor fireside room. The incident report documents the facility water will be intermittently shut off until the leaking pipe is fixed. These incidents should be reported to State Licensing within 24 hours.

The following deficiencies cited today per Title 22 Regulations.

Exit interview conducted with Human Resources Manager Wonda 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: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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Document Has Been Signed on 10/04/2022 07:05 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: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited

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(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.The following requirement has not been evidenced by:
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LPA was notified on 09/29/2022 of an incident that occured on 09/27/2022 causing the facilities water to be shut off intermettently until fixed 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: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
LIC809 (FAS) - (06/04)
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