SONRISA VILLA INC.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidential Medical and Dental: (4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidence by: Based on records review, the facility did not assist resident with obtaining their requireed medications and posed a health risk to 15 of 76 residents in care.

Official plan of correction

On 01/10/2026, the Department issued a Temporary Suspension Order and installed a Temporary Manager (TM) to oversee operations. TM reported medication management and initiated orders. This is deemed cleared during today's visit.

Deadline recorded: Feb 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.686(a)(5)

Regulation authority

HSC

What the official deficiency says

(a) A licensee shall notify the department, State Long-Term Care Ombudsman, all residents, and, responsible party in writing, within two business days... (5) A utility company has sent a notice of intent to terminate utility service on the property within not more than 15 days of the notice. This requirement was not met, as evidenced by Based on record review, the licensee did not notify the required agencies regarding terminiation of utiliyt services for 79 out 79 [R1-R79] residents which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee paid the utility bill and agreed to notify all required agencies in the event of utility services are interrupted or terminated. Licensee agreed to provide proof of paid utility bills for the month of January 2026.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.185(a)(1)

Regulation authority

HSC

What the official deficiency says

Failure to pay the required annual licensing fee shall constitute grounds for forfeiture of the license (a)(1) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. This requirement was not met, as evidenced by Based on record review, the licensee did not pay the annual licensing fee which poses a potential health and safety risk to 79 out of 79 residents.

Official plan of correction

Licensee agreed to pay balance of the annual licensing fee by POC due date.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)The licensee shall be permitted to accept or retain residents…(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each resident. This requirement was not met evidenced by: Based on record review, the licensee did not maintain hosice care plans for 18 out 18 [R1-R18] residents, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to obtain and maintain current hospice care plans for each resident receiving hospice services by POC.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility (3) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that a criminal record clearance transfer was complete for 1 of 30 staff members prior to working in the facility, which poses an immediate health, safety and personal rights risk to 79 of 79 residents in care.

Official plan of correction

Licensee agreed not to allow staff to work or be present in the facility until S1 - S4 have been fingerprinted and associated to the facility. Provide proof of Guardian Association by POC date. A civil penalty was assessed.

Deadline recorded: Jan 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that the oven in the facility kitchen was working in the facility, which poses an potential, safety and personal rights risk to 79 of 79 residents in care.

Official plan of correction

Licensee agreed to ensure the oven is operable by POC date.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that the oven in the facility kitchen was working in the facility, which poses an potential, safety and personal rights risk to 79 of 79 residents in care.

Official plan of correction

Licensee purchased a 2 day supply of perishable food on 1/8/2026. Licensee will send weekly photos of purchased food items along with receipts by POC due date.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

Personnel Records(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidenced by: Based on record review, the licensee did maintain personnel records, which poses an potential, safety and personal rights risk to 79 of 79 residents in care.

Official plan of correction

Licensee agreed to ensure all staff records are current and maintained by POC due date.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

CARE OF PERSONS WITH DEMENTIA The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement was not met as evidenced by: Based on observations and record review, the licensee did not ensure approval was obtained prior to locking exterior doors. This poses an immediate safety risk to 79 of 79 residents in care.

Official plan of correction

Facility manager deactivated the locked exterior door during today's visit. Facility manager stated a written plan would be provided to CCL regarding disposition of removal or application of fire authority. A civil penalty in the amount of $500 was assessed. POC due to CCL by POC date.

Deadline recorded: Jan 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview the licensee did not comply with the section cited above in one (1) out of five (5) resident bedrooms (did not have hot water) that were inspected which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/22/2024 Plan of Correction Facility will have water heater repaired by the plan of correction due date. Facility staff will notify LPA once repairs are made and will email LPA receipt of repairs by plan of correction due dat.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance: “(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.” This requirement was not met, as evidenced by: Based on LPA observation and manager interview: Licensee did not maintain ongoing compliance with its prior-approved fire clearance, which posed an immediate safety risk to 100 of 100 residents (R1 through R100) in care.

Official plan of correction

During today’s visit, Licensee contacted a vendor to schedule service for the facility’s fire extinguishers. Licensee agreed to E-mail the completed vendor invoice and a photograph of one of the updated extinguisher service tags to LPA, by 03/05/2024.

Deadline recorded: Feb 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on records and interviews, during today’s visit, Licensee did not have continuously active auditory devices or other staff alert features to monitor exits, which posed a potential safety risk to 31 of 100 residents (R2 through R34) in care.

Official plan of correction

During today’s visit: Licensee activated (turned on) the auditory alarms at each exterior door (other than the lobby front door). Licensee agreed to retrain its staff to: a) keep all such alarms activated 24/7, and b) remind residents that such doors are to be used as emergency exits only. Licensee also contacted a vendor to repair the faulty front door alarm sensor; the appointment is scheduled for 02/08/2024. Licensee agreed to send a copy of the staff training sign-in sheet, a copy of the vendor's completed invoice, and a video of the front door alarm in action (both left and right sides) to LPA, by the POC due date.

Deadline recorded: Mar 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87505(a)

Regulation authority

CCR

What the official deficiency says

87505 Admissions Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by: Based on LPA observation and staff interview, for 1 of 100 residents (R1), licensee did not complete an individual written admission agreement, which posed a potential personal rights risk to persons in care.

Official plan of correction

Licensee agreed to coordinate with appropriate persons, as needed, to complete an Admissions Agreement for R1. Licensee agreed to E-mail a copy of the Admissions Agreement to LPA, by the POC due date. Licensee agreed to conduct an internal audit to ensure that all current residents have a signed Admissions agreement. Licensee agreed to review their internal policies/procedures, to ensure that the signed Admissions Agreement is treated as a required document at time of move-in.

Deadline recorded: Mar 5, 2024. A deadline is not proof that correction was completed.