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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 10/31/2023
Date Signed: 10/31/2023 01:23:01 PM


Document Has Been Signed on 10/31/2023 01:23 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: 19DATE:
10/31/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Charity Butler
Licensee, Sukhjit Sandhu		TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at American Assisted Living for the purpose of conducting a Case Management-Legal/Non-Compliance Inspection. LPA was greeted at the door by Caregiver, Charity Butler, and was granted access into the facility. Suisun Fire Marshall, Jose Collins arrived at 11:15 AM. Licensee, Sukhjit Sandhu arrived at 11:30 AM.

During the Case Management-Legal/Non-Compliance Inspection, LPA toured the facility with the Licensee and the Suisun City Fire Marshall. LPA and Fire Marshall found auditory devices are operational and working at this time. Gas heaters located in staff lounge was not obstructed and uncovered. Licensee shared that the wooden sliding wall panel will be taken out. During the tour, the LPA, the Fire Marshall and the Licensee observed that the garage was filled with boxes, beds and clutter that could pose a fire danger due to the Washer and Dryer being located in the garage (See LIC 809D & LIC-812 Observation/Photo). LPA educated the Licensee regarding the importance of having the garage clean and free from clutter. Also, during this inspection, LPA, Fire Marshall and Licensee observed that the front door lock is non-operable and the locking mechanism itself is not functioning (See LIC 809D & LIC-812 Observation/Photo). LPA discussed with Licensee regarding record keeping and ensuring that resident records have all the appropriate documentation as outlined in Title 22 regulations (See LIC 9102-Technical Advisory). LPA requested the following document:

-Facility Sketch

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given to Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to Licensee, Sukhjit Sandhu.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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Document Has Been Signed on 10/31/2023 01:23 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: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
87307(d)(2)

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87307 Personal Accommodations and Services:
(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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Plan of Correction shall include filling out an LIC 9098-Self Certiifcation form and ensuring that ALL locks on doors are operable and the locking mechanisms are working and operable. In addition, Licensee shall fill out a statement on how future compliance will be met.
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This requirement was not met as evidenced by:

During the tour of the facility, LPA, Fire Marshall and Licensee observed that the front door lock is non-operable and the lock itself is not functioning which poses a potential Health, Safety and Personal Rights risk to the residents in care.
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Plan of Correction due on November 7, 2023.
Type B
11/07/2023
Section Cited
CCR87303(a)

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87303 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.
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Plan of Correction shall include filling out an LIC 9098-Self Certiifcation form and ensuring that the entire facility the garage is free from clutter. In addition, Licensee shall fill out a statement on how future compliance will be met.
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This requirement was not met as evidenced by:

During the tour of the facility, the LPA, the Fire Marshall and the Licensee observed that the garage was filled with boxes, beds and clutter that could pose a fire danger due to the Washer and Dryer being located in the garage which poses a potential Health, Safety and Personal Rights risk to the residents in care.
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Plan of Correction due on November 7, 2023.
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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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