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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 09/02/2022
Date Signed: 09/02/2022 02:26:24 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
05/13/2022 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220513173528
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:BROUSSARD, EUGENIEFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 23DATE:
09/02/2022
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Eugenie BroussardTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility failed to report resident incidents to all required parties
Facility failed to meet residents care needs
Facility failed to seek timely medical
Resident is not receiving Physcian's Order(s) as prescribed
Resident has unexplained injuries and bruising
INVESTIGATION FINDINGS:
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On 9/2/22 Licensing Program Analyst (LPA) Walters arrived unannounced to deliver findings for the above complaint allegations. LPA was greeted by staff, the Administrator, Eugenie Broussard arrived later.

The department received this complaint on 05/13/2022. On 05/17/2022, LPA conducted a tour of the facility and gather information. During the course of this investigation, LPA gathered resident R1’s Admission Agreement, Physician’s Report (LIC 602), pictures, Needs and Service Appraisal, MAR and Centrally stored Log, shower schedule, Staff charting notes, incident reports, hospice records, and interviewed staff and various parties.

Continued on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
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 5
Control Number 21-AS-20220513173528
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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2022
Section Cited
CCR
87466
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87466 Observation of the Resident : The licensee shall ensure that residents are regularly observed for changes in physical... functioning and that appropriate assistance is provided when such observation reveals unmet needs... (continued --->)
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Administrator to submit a statement that they understand regulation 87466 and shall be in future compliance ensuring residents are are regularly observed for changes.
Administrator to submit statement as the Plan of Correction (POC) by due date 09/06/2022 to Community Care Licensing attention LPA Katrina Walters to clear the citation
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Based on record review and interviews conducted: Facility staff failed to ensure proper care & supervision for R1 which resulted in R1 sustaining injury and not receiving timely care. This is an immediate health, safety and personal rights risk to the residents in care.
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Type A
09/06/2022
Section Cited
CCR
87465(a)(4)
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87465(a)(4): Incidental Medical and Dental Care Services. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility administrator will submit proof of that they have conducted an audit of all resident's medications. Plan of Correction (POC) by due date 09/06/2022 to Community Care Licensing attention LPA Katrina Walters to clear the citation
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Based on record review, observations and interview The facility failed to ensure R1's medication was provided as prescribed by physcian
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220513173528
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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2022
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need...
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Administrator will conduct inservice, to ensure staff understand regulation 87465 and how to assess residents and seeking medical attention in a timely manner. Adminsitrator to send proof of POC to LPA Walters.
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This requirement is not met as evidenced by: Based on interviews and record review after learning that R1 had injury the facility staff did not contact seek immediate medical attention.This posed an immediate health, safety or personal rights risk to persons in care.
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Type A
09/07/2022
Section Cited
HSC
1569.269
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§1569.269 Enumerated rights; severability: (a) Residents...shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff... to meet their needs. This requirement was not met as evidenced by:
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Administrator to submit a statement that they understand Health & Safety Code 1569.269(a)(6) and shall be in future compliance to meet the needs of residents in care.
Administrator to submit statement the Plan of Corrections (POC) by due date to LPA Walters
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Based on observation, record review and interviews, resident R1's care needs were not met, when staff failed to assess resident for further injury and seek medical attention. This poses an immediate health and safety risk to persons in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220513173528
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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
87705(b)(1)
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87705 Care of Persons with Dementia (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. This requirement was not met as evidenced by:
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The Administrator will develop procedures for notifying responsble parties,physcian and health care agency when there is a change of condition. Administrator to ensure that all staff are aware of condition changes. Administrator will send proof of POC to LPA Walters.
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Based on interviews and record review, the facility did not notify home health or physcian that R1 had a change of condition. This poses a pontential health and safety to residents in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220513173528
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: 09/02/2022
NARRATIVE
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Allegations- Resident has unexplained injuries and bruising, Facility failed to meet residents care needs, Faciltiy failed to seek timely medical, Facility failed to report incidents to all required parties. The interviews, observations and facility notes reveal that on 5/4/2022, during a home health visit, resident R1 reported to agency and staff that they fell two days prior. Per interviews with staff, they were unaware that R1 had fallen, however pictures and notes reveal that R1's skin tear was bandaged prior to home health's arrival. (pictures taken). In addition, R1 is supposed to be receiving 1:1 care outside of their bedroom, and hourly checks as documented on staff checklist. LPA was able to verify that the skin tear was not reported to the home health agency after it was bandaged. Notes also reveal that on 5/4/22 R1 complained of pain in their ribcage area, however R1 was not transported to the hospital until 5/5/22, where they were diagnosed with fractured ribs.

Allegation- Resident is not receiving Physcian's order(s) as prescribed. LPA reviewed R1's medication and observed that R1 was being given medication that was not prescribed to them, LPA also observed that R1 was given more medication than the physcian prescribed. (pictures taken). R1's medication records did not indicate that there were any medication changes.

Based on the information obtained during the course of the investigation through interviews, and record review a preponderance was established to SUBSTANTIATE this complaint. 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 and Health and Safety Code (cited on 9099-D). Appeal rights given to the Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5