486803815-4-23-2021-21-AS-KMOA-C2KMWN-20210430095837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 04/23/2021
Date Signed: 04/23/2021 04:54:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2020 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20201230163704

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR:	SANDHU, SUKHJIT		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 17	DATE:	04/23/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Genie Broussard, Administrator		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not staffed properly.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/23/2021 Licensing Program Analyst (LPA) Tobola met with Administrator Genie Broussard to deliver compliant investigation findings. LPA met by tele-visit due to COVID-19 precautions. LPA reviewed facility documents and conducted interviews with staff and outside parties.

The complaint alleges that facility is not staffed properly. Based on interviews with staff and outside parties and a review of staffing time-sheets, LPA found that between 12/16/2020-12/31/2020 there was only 1-2 working staff on several shifts. However, the facility does not have any required staffing ratio to meet resident needs. In addition, LPA received contradicting information during interviews with staff and outside parties thus lacking substantial evidence.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies cited. Signatures on file.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

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 1