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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 11/04/2020
Date Signed: 11/04/2020 02:33:06 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
08/19/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200819121036
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: DATE:
11/04/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Eugenie BroussardTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Neglect of resident resulted in pressure sores
Facility did not observe changes in resident's health



INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Eugenie Broussard for the purpose of delivering findings on the above captioned complaint allegations. Tele-visit conducted due to COVID-19 precautions. Complainant alleges R1 developed pressure sores due to neglect and that staff did not observe changes in R1's health. The allegations are denied. This Department has investigated the allegations by interviewing witnesses and by obtaining and reviewing records, including medical records. The following determinations have been made: R1 was admitted to a medical facility on 8/18/2020 when R1 was found to be unresponsive; facility records suggest that R1 was checked on 8/17 at noon, 8 PM, 10 PM, 8/18 at 4 am, 6 am and was observed by staff to be responsive when not sleeping. At approximately 7:45 am on 8/18 R1 was found unresponsive and was sent out; Staff report observing skin sores on 8/17 and claim a care plan for skin issues was being developed at the time R1 was sent out; Hospital records indicate R1 at risk for pressure ulcer and with multiple excoriations but with no rashes or lesions; Personal Physician for R1 has not responded to Department's request for opinion regarding care received by R1 at facility; R1 states that R1 does not believe R1 had pressure injuries while in care at the facility. CONTINUED ON PAGE TWO
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
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-20200819121036
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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Although the allegations may be true, or valid, based upon the interviews conducted and records reviewed, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
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
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
08/19/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200819121036

FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: DATE:
11/04/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Eugenie BroussardTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility not assisting resident with toileting
Facility neglected care of resident's feet
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Eugenie Broussard for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted by tele - visit due to COVID - 19 precautions. During the course of this investigation, the Department has conducted interviews with witnesses and obtained and reviewed records, including medical records. The following determinations have been made: R1 was admitted to a medical facility on 8/18/2020; Hospital records indicate that, upon admittance, R1 was observed to be covered with dry feces and presenting with bilateral feet which appeared "unkempt and not taken care of with significant slough with possible fungal growth.." R1 has relocated to another facility and has stated that R1 often waited an unreasonable time to be changed and cleaned by staff. Facility staff state that R1 is difficult to change and bath due to weight and that R1 sometimes refuses to be cleaned. Based upon statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
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: 3 of 4
Control Number 21-AS-20200819121036
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
11/09/2020
Section Cited
CCR
87625(b)(3)
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87625 MANAGED INCONTINENCE...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.***Based upon records reviewed and statements made, this requirement has not been met as evidenced by:
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Administration to provide written plan to insure compliance with 87625 going forward including protocols to be used in situations where a resident is difficult to bath and clean. Plan to be submitted to CCL by POC date in order to clear the dificiency.
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R1 states that R1 often waited many hours to be cleaned and changed by staff and, upon admittance to medical facility, R1 was observed covered with dry feces. This posed an immediate risk to the health of R1.
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Type A
11/09/2020
Section Cited
CCR
87465(a)(1)
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87465 INCIDENTAL MEDICAL AND DENTAL CARE. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based upon statements taken and records reviewed, this requirement has not been met as evidenced by:
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Administration to develop protocols to assure compliance with 87465, to include situations where a resident may need podiatric care or when a resident may be difficult to bath. Written plan to be submitted to CCL by POC date in order to clear the deficiency.
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R1 states that R1's feet have not been kept clean by staff and, upon admittance to a medical facility, R1's feet were observed looking unkempt with significant slough and possible fungal growth. this posed an immediate risk to the health of the resident.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
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)
Page: 4 of 4