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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:19:49 PM


Document Has Been Signed on 02/10/2023 02:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 16DATE:
02/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee, Sukhjit "Mantu" SandhuTIME COMPLETED:
02:30 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Licensee, Sukhjit "Mantu" Sandhu.

LPA is following up regarding two self-reported incidents involving residents R1 and R2.

Facility reported that R1 was observed with swelling on their wrist and was sent to the hospital. R1 returned to the facility with a sling and then eventually a cast. Per incident report and LPA interview with resident, R1 does not recall how they broke their wrist. R1 does not require one to one supervision and staff did not observe resident fall.

Facility reported that R2 had an incident where they were unconscious for a time. R2 was taken to the hospital and later discharged without a new diagnosis. Resident has not experienced another fainting incident since.

During inspection, LPA discussed the Change of Administrator with the Licensee and Licensee agreed to forward documents to LPA.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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