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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:16:25 PM


Document Has Been Signed on 10/21/2022 03:16 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: 64DATE:
10/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Wanda WolskiTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to the facility to conduct a health and safety case management visit. LPA met with Human Resources Manager (HRM), Wanda Wolski, and explained the purpose of the visit.

LPA Valerio and LPM Richardson toured the facility to ensure compliance with Title 22 regulations. The department observed the meal being served for lunch, facility common areas, resident bedrooms, bathrooms, and outside area. During the visit, LPA and LPM interacted with residents and staff through out the visit. In the kitchen area, near the sinks, LPA Valerio observed discolored black spots on the wall above and around the sink area. This area is used for washing dishes. This observation is an immediate health and safety risk to residents in care. Near the kitchen, there is an exit door that leads to an outside area. Along the walls on the outside area, a person is able to see windows that lead into resident bedrooms. Outside one of the bedrooms, a sharp object, switchblade knife, was observed on the ledge of the window. This observation is an immediate health and safety risk to residents in care.

Facility files for staff and residents were reviewed. LPA Valerio, LPM Richardson, and HRM Wanda reviewed the facility roster retrieved from Guardian. It was observed that staff 1 had an eligible clearance; however, effective 07/18/2022 the clearance was no longer valid. Staff 1 was confirmed by HRM Wanda to be on the schedule this week and days prior. The facility was previously cite on 09/30/22 for allowing persons to work without an approved fingerprint clearance. Due to the repeat violation, an immediate civil penalty of $1000.00 is hereby assessed. A civil penalty of $100 per day may be accrued until staff 1 is removed and no longer works for the facility. Effective 10/21/22, HRM Wanda stated that the staff member has been removed.

Per California Code of Regulations (CCR),Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC-809D. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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 3


Document Has Been Signed on 10/21/2022 03:16 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: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by:
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Based on observations, there are black discoloration spots along and around the walls in the kitchen area. This poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
10/22/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents... (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
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Based on observations, the facility did not ensure a switchblade knife was inaccessible to resident, 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/21/2022 03:16 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: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2022
Section Cited

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87355 Criminal Record Clearance(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidenced by:
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Based on records review, interviews, and observation, the licensee did not ensure staff 1 maintained an active fingerprint clearance, 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3