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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:47:51 PM


Document Has Been Signed on 04/02/2024 04:47 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:
04/02/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Caregiver, Charity Butler
Licensee, Sukhjit "Mantu" Sandhu		TIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/2/2024, Licensing Program Analysts (LPA's) Tobola and Matialu arrived unannounced for the purpose of conducting a quarterly non-compliance visit and was greeted by Lead Caregiver staff, Charity Butler. Licensee, Mantu Sandhu arrived later in the visit. LPA's toured the facility with staff and observed the front door alarm and garage alarm in need of replacement. The Licensee was informed at a previous inspection but has not been addressed. Licensee, replaced the front door alarm unit at the time of visit.

The facility garage that holds chemicals, cleaning supplies and other items that could place residents at risk was found to be unsecured and accessible. Staff were not aware of where the lock for the facility garage was located, indicating a lack of safety measures implemented by the facility. The garage door frame is also in need of replacement. In addition, LPA's observed powdered bleach and a razor and located in communal restroom as well as a disinfectant solution in resident bedroom, all of which were unsecured. Licensee removed and stored items immediately.

During a tour of the facility, LPA's observed the facility in poor sanitary condition. Spiderwebs, spiders, ants and other insect remains were located in a majority of the rooms throughout the facility. Feces were found on the floor and open trash bin of resident's (R1) bedroom. Resident (R2's) bedrooms located near the front of the facility entrance were observed by LPA's to have a strong smell of urine that Licensee has been informed of in previous visits. Licensee has agreed to implement a documenting system for staff to sign off when conducting room cleaning and continence care for R2 and other residents that require the assistance. There is an overall need for general cleaning for the facility.

Multiple holes were found in several resident bedrooms walls in need of repair. In addition, window screens located in several resident bedroom and the kitchen area were found to be missing or in need of repair potentially causing insects to enter the facility.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 04/02/2024 04:47 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: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2024
Section Cited
CCR
87505(f)(2)

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87505 Care of Persons with Dementia (f)(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This was not met at evidence by:**
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Licensee immediately removed all hazardous items from resident access and placed them in a secured location. Licensee agrees to ensure all storage containers are kept secured. Licensee to submit LIC9098 Proof of Corrections for to CCLD ensuring complinace by POC date 4/10/2024.
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During the tour of the facility, LPA's and Licensee observed several items including, powder bleach, a razor and disinfecting cleaner accessible to residents in care. In addition, resident (R2) was observed accessing the medicaiton room with no staff supervision and accessing their medicaiton storage. Additional medication not belonging to R2 were present. This serves as an immediate Health and Safety risk.
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Type A
04/03/2024
Section Cited
CCR87307(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. This was not met as evidence by:
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Licensee agrees provide a plan of action to address the areas of concern to CCLD. In addition, Licensee to submit LIC9098 Proof of Corrections for to CCLD agreeing to remain in compliance by POC date 4/10/2024.
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During the tour of the faciltiy, LPA's observed outdoor emerency exit paths located on both sides of the faciltiy to be obstructed by a matress and by plant overgrowth. This serves as an immediate safety risk to residents in care.
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Licensee immediately removed mattress from exit pathway. In addition, Licensee agrees to remove plant overgrowth from exit pathway and provide photo corrections to CCLD by POC date 43/2024.
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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


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
VISIT DATE: 04/02/2024
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During the visit, staff began the process of cleaning debris, insect and other items. Upon a tour of the outside premise of the facility, LPA's observed emergency exit pathways on both sides of the facility obstructed by a mattress and plant overgrowth. Administrator removed mattress immediately and agrees to remove plan overgrowth. During the inspection, LPA's were located in the medication room and observed a resident (R1) walk into the medication room unsupervised and placed a lighter in a cabinet with their medications stored. The cabinet was not locked and several other medications not belonging to R2 were accessible to R2.

LPA's observed several oxygen tanks located in resident bedroom. LPA's informed that resident is no longer admitted to the facility and facility agrees to secure oxygen tanks with proper signage posted on the bedroom door. In addition, facility will be contacting medical supply services to schedule oxygen tanks and other medical items no longer used by residents for pickup. Upon a sample review of staff training, LPA found a sufficient number of hours completed correlated to the calendar year. The facility will be completing the remainder of staff training within the next several months.

LPA's issued Technical Violations for the following areas:
- Auditory alarm system
- Food Safety concerns of perishable food handling/storage
- Several oxygen Tanks and medical items
- Proper facility forms and resident right and reporting posters listed in common area

Licensee and LPA's discussed Technical Support Services with Licensee indicating interest. LPA's to follow up on referral.

***Civil Penalties assessed in the amount of $500.00 for repeat violations within a 12-month period for regulations 87307(d)(2) Personal Accommodations & 87303(a) Maintenance and Operation.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/02/2024 04:47 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: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
87303(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** This was not met as evidence by:
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Licensee agrees provide a plan of action to address the areas of concern to CCLD. In addition, Licensee to submit LIC9098 Proof of Corrections for to CCLD agreeing to remain in compliance by POC date 4/10/2024. Licensee has also agreed to implement documenting system for staff to
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During the tour of the faciltiy, LPA's observed a general lack of cleanliness and items in need of repair which include:
- spiderweb and insect remains/debris
- feces and debris in resident bedrooms
- strong urine odor near front of facility
- window screens
- holes in resident bedroom walls
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sign off confirming completion of room cleaning and continence care for residents. Licensee and LPA's discussed potential plan of action for contracted cleaning service. Licensee to provide details of plan of action once determined. ***This is a repeat deficiency in less that 12 months resulting in Civil Penalties, Civil Penalties are being assessed in the amount of $250.00.

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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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