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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:45:14 PM


Document Has Been Signed on 10/11/2023 01:45 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: 20DATE:
10/11/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sukjhit Sanhdu, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Manager, Kimberley Mota, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst’s (LPA’s) Dominic Tobola, Farhaan Sarangi, Araceli Canela met with Licensee/Administrator, Sukhjit Sandhu for the purpose of reviewing issues during a Non-Compliance Conference.

The purpose of this office meeting is to discuss Non-Compliance plan (NCC) which will be extended due to items of concerns about the operation of the facility not being resolved. Parties present during this meeting agreed to extend the Non-compliance plan until 8/13/2024. Original NCC plan went into effect 8/13/21. The Regional Office will re-review progress made on Non-Compliance Plan of one year prior to its expiration date. Areas of improvement have been identified regarding reporting requirements and retaining residents with pressure injuries. Areas of compliance not limited to below were discussed:

· POCs not fully resolved


· Administer duties/qualifications
· Insufficient care and supervision
· Building and grounds
· Auditory devices
· Fire clearance concerns (Fire Department involvement)
· Staff training requirements
· Facilities future compliance

Licensee agreed to TSP service.
No deficiencies cited during the Non-Compliance Conference.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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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