486803815-5-13-2022-21-AS-KWAS-CEDT5L-20220513142544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 05/13/2022
Date Signed: 05/13/2022 02:25:52 PM

Document Has Been Signed on 05/13/2022 02:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	BROUSSARD, EUGENIE		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 22	DATE:	05/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Charity Buttler		TIME COMPLETED:	02:38 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a 1-year required annual inspection and was greeted by Staff, Charity Buttler. The Administrator was not available for today's visit. The Licensee, Mantu Sandhu arrived later. The facility has submitted a mitigation plan which was approved by Community Care Licensing on 07/06/21. This visit will focus on the infection control of this facility. Upon entry there were two sign-in binders, with a temperature gun for visitors and home health providers. Staff sign-in on binders at a separate entrance. All staff were wearing mask. LPA continued to tour the facility with staff and made the following observations. 1 of 4 bathrooms was not supplied with hand washing supplies. LPA also observed that the shower head had been removed and was laying on the floor. (pictures taken). Non-Slip mats used by resident were discolored and had mold on it. (pictures taken) In the third bathroom, the hand railing had fallen out. (pictures taken) Resident's bedroom had all necessary items as required per regulation. LPA observed that bedroom 6's door knob was taken off. Per interviews with staff the knob was taken off prior to the resident moving into the bedroom an was never placed back on. In the entertainment room, a floor board had lifted. LPA informed Licensee of the safety issue. Licensee agreed to repair. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/13/2022

NARRATIVE

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Facility has at least a 30 day supply of Personal Protective Equipment (PPE). Signs were posted throughout the facility to promote droplet precautions. Vaccination records for staff and residents are stored in a binder. Per interviews with staff, they have all received infection control training. LPA is requesting that Administrator documents all training's and sends LPA copies. Interviews also revealed that facility staff meet quarterly with Kaiser doctor, who informs them of the latest COVID guidelines and infection control.

The facility previously submitted a mitigation plan that was approved by Community Care Licensing, but since then there have been updated regulatory requirements related to infection control prevention and mitigation for communicable diseases. LPA is requesting that the facility submits an updated mitigation plan by 6/30/22. LPA provided a copy of new requirements in PIN 22-13 ASC and PIN 22-07.

California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC- 809-D. Exit interview conducted with Licensee, Mantu Sandhu Appeal Rights provided. LPA provided MS with a copy of the report. 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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2022 02:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above, The following areas of disrepair were observed: floor boards, hand railings, door knob, abd shower head. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee to ensure facility is maintained is a clean and safe manner. Licensee will make repairs, clean and disinfect areas, and order new slip mats and send LPA pictures by 5/25/2022

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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