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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 03/09/2023
Date Signed: 03/09/2023 08:25:41 PM

Document Has Been Signed on 03/09/2023 08:25 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: 16DATE:
03/09/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Violet TafallaTIME COMPLETED:
05:06 PM
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Licensing Program Analysts (LPA) Araceli Canela arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Med Tech, Violet Tafalla; Administrator, Eugenie Broussard is no longer employed by this facility and Licensee, Mantu Sandhu was not available during this visit, but was available by phone and agreed to send in copies of change of administrator paperwork that they stated was previously submitted to the department, for review.
LPA conducted a walk-through of the entire 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 Staff, Violet Tafalla.
  • Auditory alarms were found to either not working or not in place in bedrooms 2 & staffs break room which is accessible to residents.
  • Bedrooms 1, 2 & 4 had child door lock covers on the doorknobs to prevent the door from opening and bedroom 1 also requires you to open both door knobs at the same time in order for the door to open. Resident R3 who is bedridden per Physician report dated 10/19/2022 was in a non-ambulatory room that was not approved for bedridden by the Fire Department & CCL
  • Incident report was not submitted to Community Care Licensing (CCL) for resident R4, as required within 7 days.


LPA also reviewed two staff records. 2 of 2 staff records have the required training. LPA consulted regarding correction of bedroom numbers, personal rights and resident medical assessments.
A civil penalty was issued today for $250.00 for repeated citation within 12 months and an additional $500.00 for Fire safety violation and locked resident doors. 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 & appeal of rights provided by email to licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2023 08:25 PM - It Cannot Be Edited


Created By: Araceli Canela On 03/09/2023 at 04:23 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: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met. as evidenced by: during this inspection LPA observed,
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Facility to remove all doorknob covers and correct bedroom #1 so door can properly open, and send in written statement they understand Regulation. Move R3 to an approved bedridden room.
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Bedrooms 1, 2 & 4 had child door lock covers on the doorknobs to prevent the door from opening & resident R3 who is bedridden in an non approved bedriddden room by the Fire Dpt. This is an immediate risk to the health & safety of residents in care. A $500.00 civil penalty was assessed for Fire Safety Violation, Zero Tolerance.
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In addition, facility to provide staff training regarding requirement and send in POC by 3/10/2023 attention LPA A Canela
Type A
03/10/2023
Section Cited
CCR87705(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:Based on observation the licensee did not comply with
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Licensee to send in written plan on how they will ensure they meet regulation and place auditory alarm on the exit doors that are not working or missing.
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the section cited above in 2 out of 8 door alarms not working, which poses an immediate risk to the health, safety of residents in care. A civil Penalty for repeated citation within 12 months assessed today for $250.00
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POC due date to LPA
A Canela by 3/10/2023
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
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2023 08:25 PM - It Cannot Be Edited


Created By: Araceli Canela On 03/09/2023 at 04:42 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: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited
CCR
87211(a)(1)

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87211(a) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence
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Facility to send in written plan on how they will ensure they follow regulation. Facility to send in report and provide
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of any of the events specified in (A) through (D)...... This requirement was not met, As evidenced by: Licensee failed to send in and report incident for resident R4 who was sent to the Hospital since 2/22/23 & not reported, this is a potential risk to the health & Safety of residents in care.
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Proof of staff training, with signatures of staff.

POC due date 3/24/2023 attention LPA A Canela

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
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