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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 06/19/2025
Date Signed: 06/19/2025 05:47:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250618151901
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 20DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eugenie Broussard, Facility ManagerTIME COMPLETED:
05:46 PM
ALLEGATION(S):
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Facility staff did not provide adequate supervision resulting in resident eloping from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nakagawa and Contreras arrived uannanounced at 2:00 PM on 06/19/2025 to open a complaint investigation and deliver findings regarding the above complaint allegation and met with Eugenie Broussard, Facility Manager. Facility Administrator was not on site. There were 3 additional care staff and 20 residents on site at the time of visit.

Complaint alleges that Facility staff did not provide adequate supervision resulting in resident eloping from facility. Per statement filed by reporting party, resident (R1) who has a diagnosis of Dementia was found wandering on the sidewalk outside without assistance or supervision at approximately 1:30 PM by the reporting party and assistance given and facility staff notified.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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 3
Control Number 21-AS-20250618151901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
VISIT DATE: 06/19/2025
NARRATIVE
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Continued from 9099....

The allegation that Facility staff did not provide adequate supervision resulting in resident eloping from facility is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Immediate Civil penalties are being assessed in the amount of $1000 for lack of care and supervision of resident by facility staff.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20250618151901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2025
Section Cited
CCR
87705(b)(2)
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This is an amendment:87705 Care of Persons with Dementia(b)In addition... the plan of operation shall address the needs of residents with dementia(2)(2) Safety measures to address behaviors... wandering, ingestion of toxic materials. This requirement is not met as evidenced by:
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Facility agrees to conduct staff training regarding dementia care including prevention of elopement. ***Amended...Immediate Civil penalties are being assess in the amount of $500 for lack of care and supervision of resident by facility staff.
Administrator to submit training date to CCLD by POC date 06/20/2025 and completed training by 06/25/2025.
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Based on LPA's interview with facility manager resident (R1) was allowed to go outside the facility unattended, which according to R1's physician's report is not allowed.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3