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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 07/27/2023
Date Signed: 07/27/2023 05:45:40 PM


Document Has Been Signed on 07/27/2023 05:45 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:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:VioletaTafalla, med tech, lead staffTIME COMPLETED:
05:39 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with Med tech, lead staff, Violeta Tafalla (S1). Administrator, Mantu Sandhu was not available during this visit. 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.

During todays inspection, LPA toured the entire inside of the facility, with S1 and found 3 bedroom alarm doors and the main living room door turned off and not operational during inspection. This facility has several wings and residents require a auditory alert system that is operational to alert and communicate with staff if assistance is needed. LPA found some residents did not have a call light device to call staff and other systems LPA tested were not operational as no one came to assist residents. LPA also found living room door, resident bedroom doors 6,7,8,9 and 2 do not have a screen on the door. Bedroom 2 does not have a night stand and a lamp and will require room to be set up in a way that does not block the exit door once the night stand is set up. Resident R1's room had a very strong urine smell that LPA was unable to tolerate and requested facility to clean room and all linens.
Today there were 22 residents in the facility and an additional one who was said to be in the hospital since 7/3/2023. Upon LPAs arrival, there were 2 staff providing care to 22 resident, of which 6 were said to be on Hospice, 2 residents who are bedridden and an additional who requires the use of a hoyer lift to be moved and placed on electric chair. Upon arrival 1 of the staff was assisting a resident shower and the other staff was left to assist the other 22 residents. An additional staff arrived around 4:30 to assist.

LPA is unable to complete this 1 year inspection today and will return at a later date to go over all resident, staff files, facility files, plans of corrections still needed for previous citations and review medication. LPA will also return to issue citations warranted, civil penalties for repeated citations within a 12-moth period, based on LPAs observation today, July 27, 2023 and complete 1 year inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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