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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552700409
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:34:37 PM


Document Has Been Signed on 11/02/2022 01:34 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: 58DATE:
11/02/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Resident Care Coordinator, Maranda EscobedoTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a health and safety visit. LPA met with Human Resource Manager, Wanda Wolski, and explained the purpose of the visit. Resident Care Coordinator, Maranda Escobedo, arrived to the facility later during the visit.

LPA Valerio toured the facility to ensure the health and safety of the residents and staff. LPA observed 7 staff on shift. The kitchen staff were observed to be cleaning after breakfast service and prepping for lunch. Staff were observed caring for residents, passing medications, assisting with laundry, and moving residents to the television room. According to interviews with staff, there are no issues this week with toiletry supplies and kitchen supplies.

During the visit, LPA observed office staff conducting interviews for open positions. LPA reminded that all staff needed to be fingerprinted and cleared prior to starting.

LPA reviewed the schedule for the last two weeks, a copy of the LIC 500, and the guardian roster pulled from Guardian at 7:30 AM on 11/02/22. LPA observed 7 staff members not associated with the facility. Out of the 7 staff not associated, 1 staff member did not have an active cleared fingerprint on file with Guardian. The other 6 staff were observed be fingerprinted cleared. Staff Maranda emailed guardian to have the fingerprints transferred and associated by COB.

The facility was previously cited on 09/30/22 and 10/21/22 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.
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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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 11/02/2022 01:34 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: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2022
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 and 7 total staff were not associated with the facility. This 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: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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