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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 09/22/2023
Date Signed: 09/22/2023 06:55:49 PM

Document Has Been Signed on 09/22/2023 06:55 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 LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 30CENSUS: 22DATE:
09/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Sandhu SukhjitTIME COMPLETED:
04:32 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to continue the Annual Required 1 Year inspection and met with staff, Charity Butler(S2). Administrator, Mantu Sandhu arrived a few minutes later. This facility is licensed for 30 nonambulatory residents, of which 4 may be bedridden in rooms 6 and 7 only. The facility also has an approved Hospice Waiver for 10 of the 30 residents to receive hospice services. LPA previously started the 1-year inspection on 7/27/2023.
During todays inspection, LPA toured the entire inside and outside of the facility, with S2 and found 2 bedroom alarm doors and the staff room auditory door turned off and not operational during inspection. This facility has several wings and residents require an auditory alert system that is operational to alert and communicate with staff if assistance is needed. On today's inspection residents S6 pendant button was pushed and LPA waited 21 minutes and then alerted staff that no one had responded to the call button. During today's inspection the fire extinguisher was observed last serviced on 6/15/2022 and did not meet the required yearly servicing on time. LPA also went over the kitchen needing deep cleaning top to bottom and refrigerators as they all showed stuck on food, dirt, grime.
LPA is unable to complete inspection today and will return at a later date to go over the rest of the resident, staff files, facility files. LPA will also return to issue citations warranted, civil penalties for repeated citations within a 12-month period for LPAs observation today 9/22/23 and on July 27, 2023.
During todays inspection LPA found staff S7 who was recently working and was not associated to the facility as required and no proof of any training in file. All documents in the file were blank. A civil penalty for $100.00 is being assessed today for S7 not being associated to this facility
as required.
The following deficiencies were observed (see LIC 809-C) 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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Document Has Been Signed on 09/22/2023 06:55 PM - It Cannot Be Edited


Created By: Araceli Canela On 09/22/2023 at 05:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection Based on observation, interview and record review, today's visit and verification with CCL: Licensee did not ensure the regulation above due to S7 who was fingerprint cleared but NOT associated to this facility as required. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2023
Plan of Correction
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Facility to send in a written plan on how they will ensure all staff have the proper fingerprint clearance and are associated to the facility prior to working. Facility to send in proof staff S7 has been associated. Facility understands staff S7 should not be working in the facility untill all requirements are met.
POC due date 9/23/2023 attention LPA A Canela
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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