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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 06/19/2025
Date Signed: 06/19/2025 05:24:58 PM

Document Has Been Signed on 06/19/2025 05:24 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR/
DIRECTOR:		SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 30CENSUS: 20DATE:
06/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Eugenie Broussard-House Manager TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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At approximately 10:00AM, Licensing Program Analysts (LPAs) Contreras and Nakagawa made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by facility manager Eugenie Broussard. The facility is a single story home licensed for 30 residents. The facility currently provides care for 20 residents. Hospice waiver approved for 10 residents.

LPAs toured the building and grounds which was not found to be clean and not in good repair. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a sufficient supply of nonperishable foods and a sufficient supply of perishable foods as required by Title 22 Regulations. Toxins are stored in a locked garage. Knives and other kitchen supplies were stored in kitchen inaccessible to residents.

Based on LPA observation bathroom not found to be in good repair, there was no supply of paper towels with communal towel found in bathroom and no soap accessible to residents(Deficiency cited,see 809-D). There was no plastic mattress covers on beddings, incontinence smell in various resident rooms. Mattress was found to be saturated through the bottom with strong odor (Deficiency cited, see 809D..).

Water temperature did measure within regulation at faucets accessible to residents. Six out of six fire extinguisher was inspected and charged. Smoke signaling system operational. No documentation found for any disaster drills being held in the last months, last recorded drill was over a year as stated by admin. Staff held a fire disaster drill during annual inspection.

Continued on 809-C....
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
VISIT DATE: 06/19/2025
NARRATIVE
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Continued from 809-C...

Per LPA observation, bedridden resident in room #3 found in non-approved bedridden room. (Deficiency cited, see 809-D)

LPAs reviewed 4 resident records which were not all found to be well organized and not thorough.
No current admission agreement was found for 2 out of 4 resident files, R1 and R2. (Deficiency Cited, see 809-D). Needs and service plan was not completed for R1.

LPAs reviewed 4 staff files. 2 out of 4 staff records is missing LIC503- Health Assessment. 4 out of 5 did not have documentation for required completed training. LPA advised admin to submit transcripts of training for all staff.

Medications located in office were found to be secured. LPA conducted a spot check of medications for two residents. Medications were logged in completed Centrally Stored Medication Log.

In addition, LPA's conducted a Legal Non-Compliance Conference (NCC) visit during annual visit and found the following items in need of correction:

- Insufficient care and supervision
- Buildings and grounds
- Staff training requirements

These items have been cited, as included in report. Resident bedrooms unclean with unknown stains on the floors and walls, window screens in disrepair. Bathrooms lacked necessary hygiene products. Urine smell through the building and rooms. Upon review, staff training to not be present in files.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/19/2025 05:24 PM - It Cannot Be Edited


Created By: Ethel Contreras On 06/19/2025 at 03:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(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: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in bedridden resident in room #3 found in non-approved bedridden room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee to place resident in room approved designated for bedridden residents. Licensee to transfer resident to bedridden bedroom and submit pictures by POC due date 6/20/2025.
Type A
Section Cited
CCR
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in bathroom not found to be in good repair, there was no supply of paper towels with communal towel found in bathroom and no soap accessible to residents
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee to remove communal towel and replace with paper towels, place soap and trash can in bathroom. Licensee to submit pictures of replacements by POC due date 6/20/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2025 05:24 PM - It Cannot Be Edited


Created By: Ethel Contreras On 06/19/2025 at 03:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(3)(C)
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in. There was no plastic mattress covers on beddings, incontinence smell in various resident rooms. Mattress was found to be saturated through the bottom with strong odor
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee to submit proof of new linens and mattress pad coverings by tommorow POC 6/19/2025.
Type A
Section Cited
CCR
87506(b)(15)
(b) Each resident's records shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admissions Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 residents admission agreements which were found to be missing from the file during visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee to submit completed admission agreements for residents R1 and R2 by POC due date 6/20/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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