<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 10/24/2024
Date Signed: 10/24/2024 06:15:39 PM


Document Has Been Signed on 10/24/2024 06:15 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: 26DATE:
10/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Sukhjit Sandhu, AdministratorTIME COMPLETED:
06:15 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
Licensing Program Analyst (LPA) Nakagawa arrived unannounced on 10/24/2024 to conduct a Plan of Correction visit and to amend reports made on 9/21/2024 and 10/15/2024. LPA met with Administrator Sukhjit Sandhu.

The department shall assess Immediate Civil Penalties ($100 per day) for failure to correct the deficiencies cited on 10/15/2024 for each day the violation continues after citation for any of the of the following violations:

87303(f)(1) Maintenance and Operation: Solid Waste Disposal
87303(a) Maintenance and Operation: Facility Cleanliness
87506(a) Resident Records
87405(a) Administrator Qualifications and Duties


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

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, 809-D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
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 10/24/2024 06:15 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: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2024
Section Cited
CCR
87303(f)(1)

1
2
3
4
5
6
7
Maintenance and Operation: Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. This requirement was not met as evidence by:

1
2
3
4
5
6
7
Staff to immediately remove soiled continence care items located in trash bin to ensure facility being free of odors. In addition, Administrator agrees to clear facility of soiled continence care or other items at all times or upon changing residents to ensure future compliance.
8
9
10
11
12
13
14
Based on LPA observation, a strong smell of urine had been noticed upon entry to the facility, increasing in intensity towards resident bedrooms. Staff had not adequately cleaned the resident, bed or bedding, or removed soiled continence care items. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
10/16/2024
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to ensure facility is maintained is a clean and safe manner. Licensee will make repairs, clean and disinfect areas, and order new slip mats.
8
9
10
11
12
13
14
Based on observations, the licensee did not comply with the section cited above:The following areas of disrepair were observed: holes in walls, mold in ceiliing, general lack of cleanliness, immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
 Licensee to provide LPA pictures and a plan for continuous upkeep by 10/25/2024
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: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/24/2024 06:15 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: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2024
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
1
2
3
4
5
6
7
Administrator to provide copies of required documents to CCL by close of business on 10/16/2024.
8
9
10
11
12
13
14
This is evidenced by: Based on LPAs observations resident records for R1 were incomplete and lacked physician's report, pre-assessment, assessment and other required documents.This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
10/15/2024
Section Cited
CCR87405(a)

1
2
3
4
5
6
7
Administrator Qualifications and Duties:(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.This is evidenced by:
1
2
3
4
5
6
7
Administratort was not able to come to the facility due to residence a distance away from the facility, but was available by phone. LPA request a written plan from Administrator to address how they will ensure spending a reasonble amount of time in the facility, resident's care needs will be met in case of an emergency and Community Care Licensing inspections. Plan to be submitted by 10/16/2024.

1
2
3
4
5
6
7
1
2
3
4
5
6
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: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3