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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 09/28/2023
Date Signed: 09/28/2023 05:44:22 PM


Document Has Been Signed on 09/28/2023 05:44 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:
09/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff, Charity Butler & Violetta TafallaTIME COMPLETED:
02:30 PM
NARRATIVE
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On 9/28/2023, Licensing Program Analyst (LPA), Tobola and Suisun City Fire Marshall (FM), Collins arrived unannounced for the purpose of conducting a joint case management visit regarding concerns over facility fire safety and fire regulation requirements and were greeted by Staff, Charity Butler. LPA and FM conducted a tour of the facility and identified the following items in violation pertaining to fire safety inspection and serves as an immediate health & safety risk to residents in care:

- Double emergency fire doors located near living room missing safety components and in disrepair or considered non-functioning.

- Single emergency fire door located in resident hallway unable to fully close fully and in need of repair.

- Gas heaters located in staff lounge surrounded by boxes and covered by installed wooden sliding wall panels blocking sprinkler system effectiveness.

- Bedridden residents (R1) located in bedroom bedroom #9 which were not cleared by fire safety inspection as bedridden eligible bedrooms.

Continued onto LIC9099-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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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
VISIT DATE: 09/28/2023
NARRATIVE
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Licensee, Mantu Sandhu notified but was not available to meet during the visit. Report was reviewed with Licensee by phone and signed by Lead Staff, Violetta Tafalla and a copy of the report was provided. Lead Staff, signed copy of Civil Penalty Assessment form and copy provided for Licensee.

Licensee is to submit a written plan to address the immediate corrections all of the items listed in the previous report LIC809 report page. Plan is to be submitted to CCLD by POC date 9/29/2023. In addition, Licensee is to complete all corrections within 30-days of initial citation date 9/28/2023.

**Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/28/2023 05:44 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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
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Licensee is to submit fire inspection request for updated fire clearance indicating added bedridden rooms and/or relocate bedridden resident (R1) to appropriate bedridden cleared bedrooms by POC date 9/29/2023.
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Based on LPA and FM observation the Licensee placed bedridden resident in bedroom #9 which has not been granted bedridden clearance. This serves as an immediate health and safety risk to residents in care.
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**Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.
Type A
09/29/2023
Section Cited
CCR1569.269(a)(5)

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(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
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Licensee is to submit a written plan to address the immediate corrections all of the items listed in the previous report LIC809 report page. Plan is to be submitted to CCLD by POC date 9/29/2023. In addition, Licensee is to complete all corrections within 30-days of initial citation date 9/28/2023.
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Based on LPA and FM observation, the Licensee failed to ensure the safety and proper operation of several fire safety hazards:
- Emergency fire doors
- Gas heater fire hazard
- No bedridden clearance for (R1)
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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: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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