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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 11/04/2020
Date Signed: 11/04/2020 01:43:24 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200730092025
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: DATE:
11/04/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Eugenie BroussardTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not keep facility free of pests



INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Manager, Eugenie Broussard, this date, for the purpose of delivering findings on this complaint. The visit was conducted via tele-visit due to the COVID - 19 precautions. This Department has investigated the allegation that the staff did not keep facility free of pests by obtaining documents and taking statements. The following determinations have been made: Ants infested the bedroom of two residents during the period of late June and early July of this year; witnesses have observed ants in and on the beds of R1 and R2 as well as on the bodies of R1 and R2; management acknowledges the ant problem that existed and have taken steps to eradicate the pests. Based upon the interviews which were conducted, the preponderance of evidence standard has been met. Therefore, the complaint is SUBSTANTIATED.
The following deficiencies were observed (see LIC 9099D) 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
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20200730092025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2020
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.***Based upon interviews conducted, this requirement was not met as evidenced by:
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Cleared at time of visit. Management has eradicated the pests and are prepared to avoid further infestations.
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The bedroom of R1 and R2 was observed to be infested by ants on more than one occasion in June/July of 2020. This posed an immediate violation of residents' personal rights.
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Type A
11/04/2020
Section Cited
CCR
87303(a)
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MAINTENANCE AND OPERATION. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based upon interviews conducted, this requirement has not been met as evidenced by:
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Cleared at time of visit. Management has eradicated the pests and are prepared to avoid further infestations.
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The bedroom of R1 and R2 was observed to be infested by ants on more than one occasion in June/July of 2020. This posed an immediate risk to the health of the residents.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2