486803815-11-4-2020-21-AS-CMAZ-BV3345-20201104165431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 11/04/2020
Date Signed: 11/04/2020 02:07:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2020 and conducted by Evaluator Karina Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200220161220

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR:	SANDHU, SUKHJIT		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 22	DATE:	11/04/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Eugenie "Genie" Broussard, Facility Manager		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff failed to provide a comfortable environment for the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) K. Canela contacted Eugenie "Genie" Broussard, Facility Manager at American Assisted Living Facility by telephone for the purpose of delivering findings on a complaint investigation 21-AS-20200220161220. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

The Department investigated the allegations of “Facility staff failed to provide a comfortable environment for the residents”. Interviews were conducted, files and documents were requested and reviewed, the facility was toured and inspected, and a review of the facility file was done.

Report continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

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 4

Control Number 21-AS-20200220161220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMERICAN ASSISTED LIVING	FACILITY NUMBER: 486803815
	VISIT DATE: 11/04/2020

NARRATIVE

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It was reported that the facility had two resident rooms without electrical power and “left in the dark” for approximately two days. One of the two residents was observed to be non-ambulatory with an electric bed which was reportedly inoperable due to the power outage in the room. Facility staff placed an extension cord through the door to provide light into the room as a temporary fix. LPA conducted interviews and reviewed requested documents submitted. Interview with licensee, staff (S1), revealed two occasions in which the electrical power went out in a part of the facility. S1 stated one instance to be when PG&E cut the power off for no reason at all" and it was "about half a day or less like 6 hours". S1 stated another instance was when "one day, one of the breakers didn't work" and an electrician "came and said it needed to be replaced". S1 stated they "keep new breakers on hand" in case one of the breakers needs to be replaced again.

LPA requested and reviewed an inspection report dated 02/05/2020 from the Suisun Fire Department which revealed 16 observed violations from the Fire Department which include:

1.) portable extinguisher found on kitchen floor needing to be securely mounted on brackets or placed in cabinets
2.) egress doors shall be readily operable without the use of key or special knowledge
3.) egress door shall swing in direction of egress travel where serving an occupant load of 50 or more persons
4.) In the event of power supply failure, an emergency electrical system shall automatically illuminate the means of egress in areas that require two or more exits
5.) Required exit access, exits and exit discharges shall be continuously maintained and free from obstructions
6.) Where two or more exits are required from a room or area and exit access doors shall be marked by approved exit signs readily visible from any direction of egress travel
7.) Exit signs shall be internally or externally illuminated at all times; signs shall be connected to an emergency power system that provides illumination or externally for not less than 90 minutes in case of primary power loss.
8.) Delayed egress locks are permitted to be installed, with special requirements and limitations

Report continued on LIC9099-C

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20200220161220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMERICAN ASSISTED LIVING	FACILITY NUMBER: 486803815
	VISIT DATE: 11/04/2020

NARRATIVE

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16 violations observed by Suisun Fire Department continued:

9.) Extension cords and flexible cords shall not be used as a substitute for permanent wiring
10.) A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment. Storage is prohibited within this designated working space.
11.) Open junction boxes and open-wiring splices shall be prohibited. Approved covers shall be provided for all switch and electrical outlet boxes.
12.) Fire access roads shall not be obstructed in any manner, including the parking of vehicles. Traffic calming devices shall be prohibited unless approved by the Fire Code Official.
13.) New and existing buildings shall have approved address numbers placed in a position to be plainly legible from the street or road fronting the property…Address identification shall be maintained.
14.) Fire hydrant systems shall be subject to periodic testing, inspection and maintenance as required by the fire code official.
15.) Fire resistance rated construction, including but not limited to, walls, firestops, shall enclosures, partitions, smoke barriers, floors, fire-resistive coatings and sprayed fire-resistive joint systems shall be maintained.
16.) Listed single and multiple-station smoke alarms shall be installed and maintained in accordance with CFC 907.2.11.1 through 907.2.11.6 and NFPA 72

During the course of a complaint investigation, LPA reviewed records, conducted interviews, and made observations. Based on LPA observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC- 9099D. Exit interview conducted with Eugenie "Genie" Broussard, Facility Manager whose signature on this document confirms receipt of report. Appeal Rights provided.

*signature in file

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20200220161220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMERICAN ASSISTED LIVING	FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/11/2020 Section Cited CCR 87203	1 2 3 4 5 6 7	87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to act in accordance with Suisun Fire Department's regulations at all times. Facility to correct 16 violations observed by the Suisun FIre Department. Licensee to submit report copy of corrected violations form Suisun Fire department to clear the citation.
	8 9 10 11 12 13 14	Based on interviews conducted and record review, Licensee did not maintain conformity with the Suisun FIre Department's regulations by failing in a total of 16 regulations from a fire inspection dated 2/5/2020. This is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Karina Canela	TELEPHONE: (707) 588-5083
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC9099 (FAS) - (06/04)

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