486803815-4-28-2021-21-AS-KMOA-C2NV6P-20210503160953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 04/28/2021
Date Signed: 04/28/2021 04:42:28 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
04/07/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20210407104655

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:	04/28/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Genie Broussard, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident got into an altercation with another resident due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tobola and the Department conducted a complaint investigation regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Administrator Eugenie Brousard by tele-visit. Facility resident records were reviewed and interviews with staff and other outside parties were conducted.

Complaint alleges that resident R1 got into an altercation with another resident due to lack of supervision resulting in R1 needing medical care. Based on review of facility and Suisun City Police Department records LPA found no incident reports or medical calls for service regarding resident R1 relating to the allegation. Complainant was unable to provide a date the alleged incident occurred and names of those involved. In addition, LPA received contradicting information based on interviews with both staff and outside parties that they were unaware of an incident.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is 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: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

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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