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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:31:35 PM


Document Has Been Signed on 07/03/2024 04:31 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:SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
5106043825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 25DATE:
07/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Mantu Sandhu, Licensee TIME COMPLETED:
04:50 PM
NARRATIVE
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At approximately 01:46 PM, Licensing Program Analysts (LPAs) Mutialu and Tobola made an unannounced annual continuation 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.

During both initial annual inspection date 7/2/2024 and today 7/3/2024, LPA's conducted a spot review for 6 of 6 resident files and found 3 of 6 resident files missing admission agreements and pre-admission appraisals and, 3 of 6 files for residents with a diagnosis of Dementia in need of an updated Physician's Report and Needs & Service Plans. Deficiencies cited on initial annual inspection and separate complaint visits dated 7/2/2024. LPA's conducted additional file review for residents (R1 & R3) due to R1 recently sustaining a wound in the coccyx area and R3 observed with unknown bruising to their arms. LPA's contacted R1's responsible party and informed of a history of wounds as well as consistent information related to facility staff observations, notification to responsible party and medical attention. R1 is now receiving appropriate services for wound care. Facility however, is missing R1's Home Health Care Plan on file. LPA's requested for Administrator to ensure copy of Home Health Care Plan is acquired. LPA's contacted R3's responsible party and confirmed that they are aware and that R3 has a history of bruising. R3's responsible party has provided assistance with recent medical assessments and stated no indications of cognitive decline at this time. LPA's suggested for Administrator to continue observations of R3, recommending an updated medical assessment.

During tour of the facility medication room, LPA's observed several medications stored in a box located under an office desk. Found were multiple medications from several residents who have passed or no longer admitted to the facility. The medications have not been properly disposed of with Med-Tech staff unsure about protocols for medication destruction. Deficiency cited.

Administrator Mantu Sindu's Administrator Certification is not posted, Mantu Sindu to provide proof of current certification.

Continued on 809C

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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 3


Document Has Been Signed on 07/03/2024 04:31 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: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2024
Section Cited
CCR
87465(i)(1)(2)(3)(4)

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Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.
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Licensee agrees to ensure all medications left over from previous and current residents in need of disposing, are properly disposed as required. The medicaitons are to be destroyed by the facility and Administrator and staff. Administrator to submit copy of medication destruction records by POC date 7/22/2024.
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This was not met as evidence by: Based on LPA's observations, licensee did not comply with section cited above as multiple medications for several residents who are decesed or no longer admitted, were observed in medication room not properly disposed of. This poses as a health & safety risk to residents in care.
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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: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 07/03/2024
NARRATIVE
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Continued from 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC9020 Register of Facility Clients/Residents
LIC610- Disaster Plan (to include non-local evacuation site)
LIC602s- Updated
Activity Calendar
Dementia Care Plan
Evidence of Liability Insurance


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


This report was reviewed with Mantu Sindu and Appeal rights were given.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3