Community Care Licensing

Document Has Been Signed on 10/24/2024 05:37 PM - It Cannot Be Edited

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR/ DIRECTOR:	SUKHJIT SANDHU		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 30		CENSUS:	DATE:	10/15/2024
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Sukhjit Sandhu, Administrator/Licensee		TIME VISIT/ INSPECTION COMPLETED:	11:55 AM

SUPERVISORS NAME: Kimberley Mota LICENSING EVALUATOR NAME: Jill Nakagawa 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

Link to Parent Document Below:

FACILITY NAME: AMERICAN ASSISTED LIVING	FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/15/2024 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.	8 9 10 11 12 13 14
Type A 10/15/2024 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 and send LPA pictures by 10/16/2024.
	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, immediatel health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Kimberley Mota LICENSING EVALUATOR NAME: Jill Nakagawa LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024

Link to Parent Document Below:

FACILITY NAME: AMERICAN ASSISTED LIVING	FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

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.	8 9 10 11 12 13 14
Type A 10/15/2024 Section Cited CCR87405(a)	1 2 3 4 5 6 7	87405 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.
	8 9 10 11 12 13 14	Based on LPAs observations Licensee/Administrator is not on the premises to adequately perform the duties required to ensure compliance.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Kimberley Mota LICENSING EVALUATOR NAME: Jill Nakagawa LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024