486803815-10-24-2024-21-AS-KMOA-DAKNWV-20241031105010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 09/21/2024
Date Signed: 10/24/2024 04:51:12 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
09/17/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240917113159

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR:	SUKHJIT SANDHU		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 26	DATE:	09/21/2024
		UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Charity Butler, Caregiver and Sukhjit Sandhu, Administrator via phone		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff allowed resident in care to leave the facility unassisted

INVESTIGATION FINDINGS:

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****THIS IS AN AMENDED REPORT****
(Amended to include Civil Penalties)

Licensing Program Analyst (LPA) Jill Nakagawa arrived uannanounced at 10:38 AM on 9/21/2024 unannounced to deliver findings regarding the above complaint allegation and met with Staff, Charity Bulter. Administrator,Sukhjit Sandhu was available by phone. There were 2 additional care staff and 26 residents (2 receiving hospice services) on site at the time of visit.

Complaint alleges that staff allowed resident in care to leave the facility unassisted. Per LPA review of self-reported incident report dated 9/19/2024 and statement filed by reporting party, resident (R1) left the facility unassisted and without the knowledge of the staff on 9/16/2024. Reporting party (RP) found R1 walking at 6:21 PM and rendered assistance and found someone who could speak R1's language. R1 was confused and RP was aware of facility nearby. RP notified police.

(Continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240917113159

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: 09/21/2024

NARRATIVE

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Continued from 9099.....

***9099-C is AMENDED to INCLUDE CIVIL PENALTIES***

On 09/21/2024 Licensing Program Analyst did not assess immediate civil penalties (CP) in the amount of $500.00 for lack of care and supervision of resident by facility staff. LPA has returned to amend and issue a CP on the amount of $500.00. Original signatures on file on form #LIC421M.

At 6:45 PM, police had not yet arrived. Staff from facility drove up in car and returned R1 to facility after providing minimal documentation. LPA found inadequate documentation regarding R1, but did find a diagnosis of dementia, which requires a facility to have safety measures to address behaviors such as wandering.

The allegation that Staff allowed resident in care to leave the facility unassisted is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

***Amended...Immediate Civil penalties are being assessed in the amount of $500 for lack of care and supervision of resident by facility staff.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240917113159

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: 09/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2024 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia(b)In addition... the plan of operation shall address the needs of residents with dementia(2)(2) Safety measures to address behaviors... wandering, ingestion of toxic materials.	1 2 3 4 5 6 7	Facility agrees to conduct staff training regarding dementia care including prevention of elopement. ***Amended...Immediate Civil penalties are being assess in the amount of $500 for lack of care and supervision of resident by facility staff. Administrator to submit training date to CCLD by POC date 9/22/2024 and completed training by 9/24/2024.
	8 9 10 11 12 13 14	Not met as evidence by** Based on a review of facility incident report and interview with reporting party it was found that resident (R1) had eloped from the facility unattended.	8 9 10 11 12 13 14	In addition, Administrator is to submit updated physician's report and other admissions paperwork for R1 by POC date 9/24/2024..
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	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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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