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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:04:39 PM

Document Has Been Signed on 10/06/2022 03:04 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:BROUSSARD, EUGENIEFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 30CENSUS: 21DATE:
10/06/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Eugenie BroussardTIME COMPLETED:
03:12 PM
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Licensing Program Analysts (LPA) Walters arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Administrator, Eugenie Broussard and Licensee, Mantu Sandhu.

LPA conducted a walk-through of facility to address area's of non-compliance that were discussed in a compliance meeting with the facility in June of 2021.

LPA made the following observations during tour with Administrator and Licensee:
  • Auditory alarms were found to either not working or not in place in bedrooms 2 & 4
  • Bedrooms 3 & 8 smelled of urine.
  • Screens were falling off on bedroom exit 11 and 8. (pictures taken)


While LPA was present Licensee repaired the bedroom screens and called a shampooing company to have all bedroom carpets cleaned. In addition the Licensee placed auditory alarm on the bedrooms while LPA was present.

LPA also reviewed three staff records. 3 of 3 staff records reveal that staff did not have required 20 hours annual training. Additionally, residents with prohibited health care conditions have a plan to address their needs with home health.

A civil penalty was issued today for $250.00
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Appeal of Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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 10/06/2022 03:04 PM - It Cannot Be Edited


Created By: Katrina Walters On 10/06/2022 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited
CCR
87705(j)

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87705(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Licensee placed a auditory alarm on the 2 exit doors and showed LPA during facility visit. POC cleared during visit.
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Based on observation the licensee did not comply with the section cited above in 2 out of 14 door alarms which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/12/2022
Section Cited
CCR87303(a)

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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:
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Licensee to ensure facility is maintained in a clean and safe manner. Licensee to send proof of carpet cleaning by POC due date.
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Based on observations, the licensee did not comply with the section cited above, in 2 of 15 rooms smelled of urine which poses/posed a potential health, safety or personal rights risk to persons 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/06/2022 03:04 PM - It Cannot Be Edited


Created By: Katrina Walters On 10/06/2022 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
HSC
1569.625

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§1569.625 Staff training; legislative findings…This requirement isn't met as evidenced by:Based on records reviewed & interviews,licensee didn't comply w/section cited above in 3 out of 3 staff training which poses a potential health,
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Facility to ensure that all facility & agency staff have initial training required as well as on going training. Facility to provide CCLD with a plan on how facility will ensure that all staff have required training on file as well
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safety,& personal 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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