<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486803815
Report Date:
07/02/2024
Date Signed:
07/02/2024 07:56:43 PM
Document Has Been Signed on
07/02/2024 07:56 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 LIVING
FACILITY NUMBER:
486803815
ADMINISTRATOR:
SUKHJIT SANDHU
FACILITY TYPE:
740
ADDRESS:
405 KINGS WAY
TELEPHONE:
5106043825
CITY:
SUISUN CITY
STATE:
CA
ZIP CODE:
94585
CAPACITY:
30
CENSUS:
25
DATE:
07/02/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Mantu, Licensee
TIME COMPLETED:
08:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 10:15AM, Licensing Program Analysts (LPAs) Mutialu and Tobola made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by caregiver, Charity Butler. Licensee, Mantu Sandu arrived shortly after. The facility is a single story home licensed for 30 residents
with two residents on hospice awaiting approval.
The facility currently provides care for 25 residents. In addition, there are some residents with a diagnosis of dementia.
At approximately 10:20 AM, 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 but not a sufficient supply of perishable foods as required by Title 22 Regulations. Toxins are stored in a locked room. Knives and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. LPA observed large glass mirror shard located in resident bedroom which was immediately removed (photos taken). There was a supply of cleaners and hygiene products available to residents. Based on LPA observation there was no supply of paper towels and a limited supply of toilet paper available for residents use. All resident’s bedrooms have lighting but not appropriate furnishings.
Water temperature did not measure within regulation between 103 and 122 degrees F at four of four faucets accessible to residents. One out of one bathroom sink is not working. Six out of six fire extinguisher was inspected and charged. Smoke signaling system is expired as of 06/6/2024. There was enough lighting in all common areas and resident rooms.
Continued on 809C
SUPERVISOR'S NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
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
11
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:
07/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809
Medications located in office were found to be secured. LPA conducted a spot check of medications for 3 of 3 residents. Three of which were missing medication start dates and one of which were missing full medication input on centrally stored medication.
At approximately 01:00 PM, LPA reviewed Seven of Seven staff records which were not all found to be well organized and not thorough. One of six staff have current First Aid Certificate. Five of six staff records are missing First Aid certification. Six of six staff files are missing Annual training including required Dementia and Medication Administration training. One of six staff records is missing LIC503- Health Assessment and TB Screening.
LPAs to return another day to complete annual inspection.
In addition, LPA's conducted a case management including the Legal Non-Compliance Conference (NCC) visit and found the following items in need of correction:
- Insufficient care and supervision
- Buildings and grounds
- Staff training requirements
- Reporting requirements
Based on LPA's observations the facility was not in a clean, safe and sanitary condition. LPA's observed insect remains throughout the facility and kitchen area, resident bedrooms unclean with unknown stains and matter on the floors and walls, window screens not aligned with frame or in disrepair. Upon a review of staff training to be insufficient. Lastly, the department had discovered several incidents including an incident involving resident eloping from the facility with no formal reporting from the facility. Citations have been addressed in annual inspection.
SUPERVISOR'S NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
07/02/2024 07:56 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
AMERICAN ASSISTED LIVING
FACILITY NUMBER:
486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on department records review, the licensee did not comply with the section cited above in proper reporting requirements involving resident incidents, medical attention calls and a resident elopement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/18/2024
Plan of Correction
1
2
3
4
Administrator failed to properly report incidents in a timely manner. Administrator agrees to review all elopement incidents within the last year, reconcile and submit incident reports to CCLD by POC date 7/18/2024.
Type B
Section Cited
CCR
87705(c)(5)
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 dementia residents with outdated physicians reports not completed within a 12-month period which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/18/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit completed Physician's Reports LIC602 for residents (R4, R5 & R6) to CCLD by POC date 7/18/2024.
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:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
07/02/2024 07:56 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
AMERICAN ASSISTED LIVING
FACILITY NUMBER:
486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above due to insect remians observed in the kitchen area and kitchen doorways, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2024
Plan of Correction
1
2
3
4
Administrator agrees to conduct a full general deep cleaning of faciltiy insect remains and submit a LIC9098 Proof Corrections Forms to CCLD by POC date 7/22/2024 confirming completion.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and spot medication count, the licensee did not comply with the section cited above in 3 out of 3 medicaiton records without start dates and 1 of which with a missing medicaiton input on the centrally stored medication records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2024
Plan of Correction
1
2
3
4
Administrator agrees to conduct an in-service training with all med-tech staff on proper medication record protocols. In addition, Administrator to place written reminder for staff in medication room for protocols. Photos of posted protocol and completed training to be submitted by POC date 7/22/2024.
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:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
07/02/2024 07:56 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
AMERICAN ASSISTED LIVING
FACILITY NUMBER:
486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 admissions agreements which were found to be missing from file during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/18/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit completed admissions agreeements for residents (R1, R2 & R3) by POC date 7/18/2024.
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 provided staff records without proof of dementia training records available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/18/2024
Plan of Correction
1
2
3
4
Administrator agrees to ensure staff training is readily available for department review. In addition, Administrator agrees to submit all staff training for dementia care by POC date 7/18/2024.
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:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
07/02/2024 07:56 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
AMERICAN ASSISTED LIVING
FACILITY NUMBER:
486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 dementia residents with outdated needs & service plans not completed within a 12-month period which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/18/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit completed Needs & Service Plans LIC625 for residents (R4, R5 & R6) to CCLD by POC date 7/18/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
07/02/2024 07:56 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
AMERICAN ASSISTED LIVING
FACILITY NUMBER:
486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above due to observed insect remains throughout the facility and kitchen area, resident bedrooms unclean with unknown stains and matter on the floors and walls, window screens not aligned with frame or in disrepair, dry rot under kitchen sink cobwebbs throughout the faciltiy, mold in restroom and overall uncleanliness and minor disreapair ,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2024
Plan of Correction
1
2
3
4
Administrator agrees to hire professional cleaning service to conduct a full general cleaning of the facitliy living quarters including kitchen areas, common areas, resident bedrooms and restrooms. Proof of corrections form and receipt of cleaning service to be submitted to CCLD by POC date 7/22/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR NAME:
Stefanie Mutialu
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/02/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/02/2024
LIC809
(FAS) - (06/04)
Page:
11
of
11