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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:21:57 PM


Document Has Been Signed on 01/23/2024 02:21 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: 21DATE:
01/23/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Caregiver Staff, Charity Butler & Lead Staff, Violetta TafallaTIME COMPLETED:
02:35 PM
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On 1/23/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of a quarterly Non-Compliance (NCC) visit and was greeted by Lead Staff, Chartiy Butler (S1). Staff attempted to contact Administrator, Mantu Sandhu with no success. LPA conducted a tour of the facility with S1 found the facility to have a strong smell of urine coming from the resident bedrooms located towards the front of the facility. Staff S1 explained the current continence care plan for a resident (R1). S1 immediately replaced R1's trash bin containing soiled continence care items to ensure the facility is free from any odors. Technical Violation issued. Previous NCC visit conducted by LPA, Sarangi indicated deficiencies regarding damaged door lock located at the front door of the facility, and the garage storage area not kept in clean and safe conditions putting facility at risk of fire hazard. Upon inspection, LPA found both items to have been addressed.

Upon inspection, LPA observed the auditory alarm located at the front entrance to the facility in need of replacement battery or complete replacement due to low auditory sound emitted. Administrator to resolve auditory device issue and submit documentation confirming corrections. Technical Advisory issued. Staff S1 left during the visit for the end of their shift. Later in the inspection, Lead Staff, Violetta Tafalla (S2) arrived to complete the inspection.

No deficiencies cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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