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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 07/02/2024
Date Signed: 07/02/2024 06:39:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240626084453
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: 25DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Mantu Sandhu, Administrator & Charity Butler, Lead CarestaffTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Licensee did not ensure that an pre-admission assessment was performed on resident prior to acceptance of resident
INVESTIGATION FINDINGS:
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On 7/2/2024, Licensing Program Analysts (LPA's) Tobola and Mutialu arrived unannounced for the purpose of initiating complaint investigation and was greeted by Lead Carestaff, Charity Butler. Administrator, Mantu Sandhu arrived later in the visit. LPA's toured the facility, interviewed staff and residents, reviewed records and made observations during the course of the investigation.

Complaint alleges licensee did not ensure that a pre-admissions assessment was performed on resident prior to acceptance of resident. Based upon file review, LPA's found that 3 out of 3 residents (R1, R2, R3) did not have proper pre-appraisal assessment on file. In addition, upon interview, Administrator confirmed that the pre-appraisal assessments were not completed prior to residents' admissions.

Allegation, licensee did not ensure that an pre-admission assessment was performed on resident prior to acceptance of resident is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240626084453

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: 25DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Mantu Sandhu, Administrator & Charity Butler, Lead CarestaffTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not allow resident to go on outings
Personal Rights
INVESTIGATION FINDINGS:
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3
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5
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7
8
9
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13
On 7/2/2024, Licensing Program Analsyts (LPA's) Tobola and Mutialu arrived unannounced for the purpose of initiating complaint investigation and was greeted by Lead Carestaff, Charity Butler. Administrator, Mantu Sandhu arrived later in the visit. LPA's toured the facility, interviewed staff and residents, reviewed records and made observations during the course of the investigation.

Complaint alleges staff do not allow residents to go on outings. Based upon interviews with residents (R2, R4, R5 & R6) there were inconsistent and contradicting statments regarding allegation. In addition, based upon record review, LPA's found that the alleged victim is not able to leave the facilty unassisted.

Complaint alleges personal rights of residents are violated, involving staff threatening, yelling and speaking inappropriately to residents in care. Based upon interviews with residents (R2, R4, R5 & R6) there were inconsistent statement and a lack of corroborating information pertaining to the allegation.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240626084453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2024
NARRATIVE
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A finding that the complaint allegations, staff do not allow resident to go on outings and personal rights violated are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED

No deficiency cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240626084453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
CCR
87457(c)
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Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria.. This was not met as evidence by:**
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Administrator failed to complete proper assessment documentation for resident admissions. Administrator agrees to complete Needs & Service Plans for residents (R1, R2 & R3) and submit to CCLD by POC date 7/5/2024.
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Based upon review of resident records and interview with Administrator, it was found that 3 out of 3 residents do not have pre-appraisal assessments on file prior to admission. This serves as a potential health & safety risk to residents in care.
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7
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7
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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5