486803815-9-22-2023-21-AS-KMOA-CWQVUN-20231018164458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 09/22/2023
Date Signed: 09/22/2023 06:59:12 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2023 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230919142222

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR:	SUKHJIT SANDHU		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 20	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	04:34 PM
MET WITH:	Sandhu Sukhjit		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Licensee does not ensure facility grounds are maintained.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to initiate a complaint investigation regarding the above allegation and met with Administrator, Sandhu Sukhjit.

During visit LPA spoke with staff and made observations. It was alleged Licensee does not ensure facility grounds are maintained in that the faclity side yards fence is broken, there are several household items and gargabe on the premises. Based on LPA’s observations during todays inspection 9/22/2023, LPA observed the yard fence, tilting, missing wood panels and in need of all around repair. LPA also observed the left side of the backyard with two unfolded tarps laying around and the back area out side the resident rooms needing to be raked to remove debri. The entire outside perimenter need to be swept and cleaned.

Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230919142222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2023

NARRATIVE

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LPA also obtained copies of photos provided to LPA, by outside source, showing a mattress, large appliance, and garbage on the premises of the facility, but LPA did not observe any and have now been removed. Facility Administrator explained that the old mattress and appliances were items that were removed over a year ago.

Based on todays observations the preponderance of evidence standard has been met, therefore, allegations for, "Licensee does not ensure facility grounds are maintained, is found to be 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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230919142222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/20/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation (a) 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 on observation the licensee did not comply with the following:	1 2 3 4 5 6 7	Administrator to submit written plan of action for fence repairs and clean up of the facility to LPA by 10/9/2023 and proof of correction by 10/20/2.023
	8 9 10 11 12 13 14	During todays inspection, LPA toured the yard with staff and Administrator and discussed the facility wood fence needing repair, clean up of all debri in the outside yard along facility. This is a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14	Written plan will include on how facility will ensure they stay in compliance.
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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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

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