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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 06/09/2023
Date Signed: 06/09/2023 05:39:09 PM


Document Has Been Signed on 06/09/2023 05:39 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: 21DATE:
06/09/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Violet Tafalla, med tech, lead staffTIME COMPLETED:
04:53 PM
NARRATIVE
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Licensing Program Analysts (LPA) Araceli Canela arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Med Tech, Violet Tafalla; Administrator, Mantu Sandhu was not available during this visit, but was available by phone.LPA conducted a walk-through of the entire facility to address area's of non-compliance that were discussed in a compliance meeting with the facility in June of 2021.
LPA made the following observations during tour with Staff, Violet Tafalla.
  • Auditory alarms were found to either not working or not in place in 9 of the 11 doors. Resident rooms, #2,6,7,8,and #9 and front door, living room, staff lounge room and door leading outside from the patio room.
  • Incident report was not submitted to Community Care Licensing (CCL) for resident R1, as required within 7 days.
  • LPA found rooms #5, 10 and 14 to have a very strong urine odor and carpets or bedding will need to be cleaned to remove the urine smell.
  • LPA found the mens bathroom had several toxins (clorox lysol,ajax, clorox spray) under bathroom sink, not locked and 2 shaving razors. The kitchen cabinet was unlocked with several knifes and accessible to residents in care.
LPA consulted regarding Bedrooms 6,8 & 9 have a second door knob that almost got jammed 1 time out of 4 attempts and administrator has agreed to remove the second door knobs as they are not required and will prevent door from possibly jamming and not opening correctly. Facility understands if the door does not open properly at all times, the facility may be cited. LPA requested review of R2 and confirmation they meet non-ambulatory status. Thorough cleaning of bathrooms and patio room.
2 civil penalties were issued today for $250.00 each, for repeated citation within 12 months period.The following deficiencies were observed (see LIC 809D) 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 & appeal of rights provided to Violet Tafalla.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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 06/09/2023 05:39 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: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2023
Section Cited
CCR
87705(j)

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87705(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:Based on observation the licensee did not comply with
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Facility to provide proof of correction. Licensee to send in written plan on how they will ensure they meet regulation and place auditory alarm on the exit doors that are not working or missing.
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the section cited above in 9 out of 11 door alarms not working, which poses an immediate risk to the health, safety of residents in care. A civil Penalty for repeated citation within 12 months assessed today for $250.00
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Plan of correction for working auditory doors due 6/10/2023. In addition, facility to send in proof of staff training, including administrator, with signatures of staff. Training proof due by 6/14/2023 Attention LPA Araceli Canela to FAX (707) 588-5080 or email: araceli.canela@dss.ca.gov
Type A
06/12/2023
Section Cited
CCR87705(f)(1)

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87705(f)(1)Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met, as evidenced by:
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LPA requested staff to lock knife cabinet, lock or remove cleaning supplies from bathroom and shaving razors during the inspection. Facility to submit a written
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During LPAs inspection today, LPA found the mens bathroom had several toxins under bathroom sink, not locked and 2 shaving razors. The kitchen cabinet where knifes are kept was unlocked and accessible to residents in care. This is an immediate risk to the health & safety of residents in care.
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plan on how they will ensure such items are locked and not accessible to any resident. Plan of correction and proof of staff training due 6/10/203 to LPA Araceli Canela
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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/09/2023 05:39 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: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2023
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence
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Facility to send in written plan on how they will ensure they follow regulation. submit incident report for R1 and any other missing reports. Facility to provide Proof of staff training, with signatures of staff.
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(D)...... This requirement was not met, As evidenced by: Licensee failed to send in and report incident for resident R1 who was sent to the Hospital around 5/5/23 and admitted since. Facility did nt have a copy and there was no record CCL received a report, this is a potential risk to the health & Safety of residents in care.
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by POC due date 06/12/2023 attention LPA Araceli Canela FAX (707) 588-5080 or email: araceli.canela@dss.ca.gov

A civil Penalty for repeated citation within 12 months assessed today for $250.00
Type B
06/21/2023
Section Cited
CCR87625(b)(3)

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87625(b)(3) Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Facility to send in written plan on how they will ensure they follow regulation. Proof rooms have been cleaned.

POC due date 6/21/2023 attention LPA A Canela
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This requirement was not met, as evidenced by 3 out of 15 rooms have a very strong urine odor in the room. This is a potential risk to the health and safety of 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3