552700409-4-5-2021-27-NP-CACL-C24SNH-20210415140134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 552700409
Report Date: 03/30/2021
Date Signed: 04/05/2021 01:22:05 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
02/01/2021 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20210201160803

FACILITY NAME:	SONORA SENIOR LIVING		FACILITY NUMBER:	552700409
ADMINISTRATOR:	KATRYNA HUNT		FACILITY TYPE:	740
ADDRESS:	18760 CHABROULLIAN LN		TELEPHONE:	(209) 984-5124
CITY:	JAMESTOWN	STATE: CA	ZIP CODE:	95327
CAPACITY:	90	CENSUS:	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator, Katryna Hunt		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/Lack of Supervision:
1) Lack of care and supervision resulting in residents sustaining falls.
2) Facility failed to ensure resident’s with a diagnosis of dementia are properly monitored and supervised
3) Facility failed to monitor residents behaviors
Other:
1) Staff stealing residents' medication.
2) Falsifying documentation

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/30/21 at 3:00pm Licensing Program Analyst (LPA) Kevin Gould made an unannounced tele-inspection to Sonora Senior Living RCFE to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA Gould conducted interviews with eight staff members and attempted interviews with an additional staff member, S9 with no response and attempted to interview residents R1 and R2 but were unable to be interviewed due to their medical conditions. LPA also reviewed two months of medication administration for residents R3 and R4. The interviews conducted with staff were not conclusive and the allegations could not be corroborated.

Page 1 of 3

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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 5

Control Number 27-AS-20210201160803

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: 03/30/2021

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
26
27
28
29
30
31
32

Regarding residents falling: LPA interviewed two temp staff and five full time staff employed by the facility and could not corroborate the allegations. No full time staff could identify resident or residents with persistent fall incidents and temporary staff could not identify the alleged victim. Although a resident may have fallen or been observed on the ground by a staff member, LPA did not find any evidence to support the allegation.

Regarding allegations facility failed to ensure resident’s with a diagnosis of dementia are properly monitored and supervised and Facility failed to monitor residents behaviors: LPA interviewed two temp staff, five full time staff employed by the facility and attempted to interview Residents R1 and R2 and could not corroborate the allegations. Staff interviewed identified R1 as suffering from dementia and has exhibited inappropriate behaviors as a result of a change in condition (advanced dementia) that were not identified in R1's physician evaluation at intake. LPA observed documentation of physician and family outreach to address medication for R1, increased monitoring for R1 change of room from shared to single and an alarm placed on the door for R1 alerting any staff on the floor to R1's exit and increased monitoring. LPA attempted to interview R1 and R2 regarding inappropriate behavior R1 may is alleged to have exhibited on R2 but was unable to interview to due advanced dementia. LPA Gould could not corroborate allegations.

Regarding alleged stealing of medications and falsifying medication records: LPA Gould Conducted interviews with two temp staff and five full time staff employed by the facility and conducted file review of R3 and R4's medication administration and could not corroborate the allegations. Although LPA observed inconsistencies with previous months medication records and missing signatures of witnesses to verify the medication had been given to R3 and R4, LPA could not corroborate the allegations that medications had been stolen or not given to residents. LPA could also not verify that the records had been falsified as staff interviewed admitted to not witnessing medication being administered and signing as witnesses regardless. This information was verified by other staff interviews.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/Lack of Supervision and Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

Page 2 of 3

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20210201160803

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: 03/30/2021

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 26 27 28 29 30 31 32	There are no deficiencies noted or cited per California Code Regulation, TITLE 22 Exit interview was conducted with the facility administrator, a copy of this report and appeal rights will be mailed to the facility for signature. Page 3 of 3

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5