Inspection Reports for
Sonnet Hill Senior Living

The complaint alleged that facility staff were not meeting resident incontinent needs, not assisting with dressing, not providing eating assistance, and not dispensing medication as prescribed. After interviews with staff, residents, witnesses, and review of care plans and medication records, the complaint was determined to be unfounded.

The investigation found the complaint to be unfounded, meaning the allegations were false or without reasonable basis. No deficiencies were cited, and the facility staff were found to be meeting resident care needs as per interviews and record reviews.

The complaint investigation was substantiated based on multiple incident reports documenting Resident R1's elopements on January 4, 11, and 12, 2026. The facility was found to have inadequate supervision and elevator security procedures, contributing to the incidents.

The investigation found that Resident R1, who has a neurocognitive disorder and wandering behaviors, eloped multiple times due to inadequate supervision and failure to properly secure elevator access. An immediate civil penalty was assessed for the absence of supervision resulting in the elopement.

The visit was triggered by complaints regarding a medication error on January 2, 2026, and an elopement incident on January 11, 2026. The medication error was substantiated with documentation and interviews. The elopement case is under review and may warrant a follow-up visit.

The inspection found that on January 2, 2026, a medication error occurred where Resident R1 was given Resident R2's medication. Additionally, an elopement incident involving Resident R3 occurred on January 11, 2026. A Type B deficiency was cited related to personnel competency in medication administration.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or lacked a reasonable basis. Multiple interviews and document reviews were conducted, and no substantiated issues were identified.

The investigation found no evidence to support the allegations. Interviews with residents, staff, and witnesses, as well as reviews of death reports, incident reports, and facility policies, indicated that the facility met regulatory requirements and provided appropriate care and supervision. The complaint was determined to be unfounded.

The complaint alleged that staff did not notify residents and responsible parties of a possible scabies outbreak. The investigation found the allegation to be unfounded, meaning it was false or without reasonable basis.

The investigation found that two residents were diagnosed with scabies and quarantined, the facility notified residents and families, and there was no scabies outbreak. The allegations were determined to be unfounded with no citations issued.

The visit was related to Complaint 26-AS-20250623094647, which was amended from unsubstantiated to unfounded during this visit.

No deficiencies were cited during the visit according to California Code of Regulations, Title 22. An exit interview was conducted and a signed copy of the report and amended complaint were provided.

The complaint alleged staff were not following the universal precaution plan and that gowns were not provided during a viral outbreak in March 2025. After investigation, including interviews with 9 staff and 7 residents, inspection of supply rooms, and review of incident reports, the complaint was found to be unfounded.

The investigation found the complaint to be unfounded. Interviews with staff and residents, inspection of PPE supplies, review of policies and incident reports showed that the facility was following infection control protocols and there was no evidence of a viral outbreak or failure to provide PPE.

The complaint investigation was substantiated regarding improper maintenance of centrally stored medications and inaccurate medication records. Other allegations about insufficient staffing, lack of staff training, and failure to safeguard confidentiality were found to be unfounded.

The investigation substantiated that facility staff did not properly maintain centrally stored medications and did not maintain accurate medication records for residents, with 4 out of 4 resident records reviewed found deficient. Other allegations regarding staffing sufficiency, staff training, and confidentiality of residents' records were found to be unfounded.

No deficiencies were cited per California Code of Regulations, Title 22. An advisory note was provided to the administrator.

No deficiencies were cited during the visit. The Licensing Program Analyst reviewed staff training documentation, resident files, eviction notices, and the facility's corrective action plan. Some staff training documentation was missing but plans were made to complete and submit updated training.

The facility was observed to be in broad compliance with regulations, with no deficiencies cited during the visit. Reviews confirmed proper admissions agreements, staff training on resident rights and eviction procedures, and compliance with medication training and incident reporting plans.

The visit was complaint-related as deficiencies were observed during complaint investigations. Specific substantiation status is not stated.

Deficiencies were cited related to medication administration without physician orders, incomplete eviction notices, missing admission agreements, and failure to submit eviction reports to the licensing agency. Plans of correction were agreed upon including staff training and submission of training records.

The complaint investigation found that the licensee did not report 4 COVID positive cases at the facility, which posed a potential safety risk to residents in care.

The facility had 2 cases of COVID-19 among residents and 2 cases among staff that were not reported in writing to the Department, resulting in a cited deficiency for failure to meet reporting requirements.

The Licensing Program Analyst toured the facility and observed visitor screening, clear exits, adequate food and PPE supplies. No deficiencies were cited as per California Code of Regulations Title 22.

The facility was found to be in good repair with functioning safety equipment and proper installations, but some issues needed correction before licensure could be recommended, including hot water temperature, installation of evacuation chairs, and proper complaint poster size.

The applicant and administrator successfully completed the Component II evaluation via call with the analyst, confirming understanding of Title 22 regulations and facility operation requirements. No deficiencies or violations are noted in the report.