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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:57:25 PM

Document Has Been Signed on 01/24/2025 03:57 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/
DIRECTOR:		SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 30CENSUS: 24DATE:
01/24/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Sukhjit Sandhu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 01/24/2025 and met with Administrator/Licensee Sukhjit Sandhu to conduct a Non-Compliance inspection for the following compliance issues:
· POCs not fully resolved.
· Administrator duties/qualifications
· Insufficient care and supervision
· Building and grounds
· Auditory devices
· Staff training requirements
· Facility's future compliance

There were 24 residents at the time of inspection.

LPA Nakagawa met with the Administrator/Licensee and toured the facility. LPA found that the Licensee had not yet resolved all of the above items and facility remains out of compliance. The Licensee is working with TSP to address the issues but has not yet completed the requirements.

LPA discussed requirements and provided information to Administrator to aid in organization and being in full complete compliance.

LPA cited for the following:

87303(a) Maintenance and Operation: The facility shall be clean...
87405(a) Administrator Qualifications and Duties

Continued on 809-C....
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/24/2025
NARRATIVE
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Continued from 809....

LPA issued a Technical Advisory for:
87506(b)(15) Resident Records: No signed Admissions Agreement

Administrator had been asked to do a deep-cleaning of facility. At the time of inspection, the facility still required a deep-cleaning, especially the bathrooms. Resident paperwork was still incomplete but Administrator had made efforts to get paperwork organized and into binders. Administrator unable to show proof of valid Administrator's Certificate (see 809-D)

. 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2025 03:57 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 01/24/2025 at 03:30 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: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation:
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors** This was not met as evidence by:
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Licensee agrees provide a plan of action to address the areas of concern to CCLD. In addition, Licensee to submit LIC9098 Proof of Corrections for to CCLD agreeing to remain in compliance by POC date 01/27/25.
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During the tour of the faciltiy, LPA's observed a general lack of cleanliness and items in need of repair which include:
Based on LPA's observations of urine residue on bathroom walls and dirt and grime throughout building doors and walls This serves as an immediate Health and Safety risk.
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Type B
01/24/2025
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This was not met as evidenced by:
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Licensee/Administrator to provide valid copy of Administrator's Certificate and/or proof of re-certification by 01/27/2025.
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Based on valid certificate being available on line or on the facility premises.This is a potential Health and Safety risk.
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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:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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