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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 04/23/2021
Date Signed: 04/23/2021 04:59:29 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
11/16/2020 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20201116083148
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 17DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eugenie Broussard, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to provide adequate care resulting in the injury of a resident.
Facility failed to report a change in residents condition as required by Title 22.
Resident has stage three pressure injuries.
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. Resident, facility, staff and medical records were reviewed and interviews with staff and other outside parties were conducted.

Complaint alleges facility failed to provide adequate care resulting in the injury of a resident. Based on review of facility and resident medical records and interviews with staff, resident and outside parties it was found that resident (R1) required assistance with bathing, dressing, repositioning, incontinence care and transfers. Multiple staff stated that no observations were made regarding a sustained wound on R1's buttocks prior to 11/07/2020. Staff are required to provide R1 incontinence care diaper changing and repositioning every 2 hours. Facility was unable to provide record logs of R1's incontinence care changing and logs of R1's repositioning prior to 11/07/2020. R1 stated that facility does not follow care plan and that the services are not provided every 2 hours. Facility failed to observe changes in R1's skin condition and failed to seek medical attention in a timely manner.
Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20201116083148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
VISIT DATE: 04/23/2021
NARRATIVE
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Complaint alleges facility failed to report a change in residents condition as required by Title 22. Based on incident report record review and interviews with staff it was found that on 11/07/2020 R1 was transferred to a medical facility after staff observed a wound on R1's buttocks. The facility failed contact Licensing by phone or incident report regarding R1's observed wound and transfer to a medical facility in a timely manner based on Title 22 reporting requirements.

Complaint alleges resident has stage three pressure injuries. Based on review of facility and medical records, photos, interviews with staff, residents and outside parties it was found that facility resident (R1) was admitted to the hospital on 11/07/2020 after staff had observed a wound on R1's buttocks. Staff were unaware of when the wound had developed. R1 was diagnosed with an unstageable wound that falls between stage 3 and stage 4 pressure injuries. R1 had resided in the facility with a stage 3 or stage 4 pressure injury without an exception granted or provided home health or hospice services.

Based on LPA record review and interviews staff and outside parties the allegations of facility failed to provide adequate care resulting in the injury of a resident, facility failed to report a change in residents condition as required by Title 22 and resident has stage three pressure injuries are substantiated, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

***Civil Penalty assessed in the amount of $250.00 for repeat violation of regulation 87465(a)(1) Incidental Medical And Dental Care, within the last 12 months with the previous violation dated 11/4/2020.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal Rights given. Signatures on file.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20201116083148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/27/2021
Section Cited
CCR
87616(a)(1)
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87616 PROHIBITED HEALTH CONDITIONS. ..Shall not be admitted or retained in a residential care facility for the elderly..Stage 3 and 4 pressure injuries.***Based upon statements taken and records reviewed, this requirement has not been met as evidenced by:
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Administrator retained 1 of 1 resident R1 with stage 3-4 pressure injuries. Administration is to review the requirements of 87615 and will develop a plan and procedure which will ensure compliance going forward. Plan to be submitted to CCL for approval by POC date 4/27/2021 in order to clear the deficiency.
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Facility had retained and provided care for R1 while R1 had sustained a pressure injury. Medical documents state that R1's wounds were unstageable but categorized as a stage 3-4 wound. R1 was not receiving hospice care and resided in the facility without an exception. This poses as an immediate health and safety risk to residents in care.
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In addition, Administration agrees to conduct a vendored training for all staff on prohibited health conditions. Training to be scheduled by POC due date 4/27/2021. Signed proof of training to be submitted to CCL by POC due date 5/5/2021.
Request Denied
Type A
04/27/2021
Section Cited
CCR
87465(a)(1)
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87465 INCIDENTAL MEDICAL AND DENTAL CARE. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based upon statements taken and records reviewed, this requirement has not been met as evidenced by:
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Administrator failed to properly arrange for medical care for resident R1 resulting in stage 3-4 wound injury. Administrator agrees to conduct a vendored training for all staff on assessing, assisting and arranging medical care for residents. Training to be scheduled by POC due date 4/27/2021. Additionally, signed proof of training to be submitted to CCL
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R1 sustained an unstageable stage 3-4 wound while in care of the facility. The facility failed to arrange for appropriate medical care for R1 resulting in R1 being injured. This poses as an immediate health and safety risk to residents in care.
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by POC due date 5/5/2021.

***Civil Penalty assessed in the amount of $250.00 for repeat violation for regulation 87465 Incidental Medical and Dental Care, within the last 12 months.
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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20201116083148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/05/2021
Section Cited
CCR
87211(a)(1)
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87211 REPORTING REQUIREMENTS. A written report shall be submitted to the licensing agency.. within seven days of the occurrence..Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. ***Based upon statements taken and records reviewed, this requirement
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Administrator failed to submit a written report to CCL in a timely manner after occurrence of resident sustaining injury while resident is under facility supervision. Administrator agrees review regulation 87211 and to develop plan and procedure to ensure reporting requirement compliance going forward.
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has not been met as evidenced by:
Facility failed to report R1's sustained injury while in care of the facility to CCL within the required 7 days. The incident occurring on 11/07/2020 was not reported by facility staff until 11/17/2020 when contacted by CCL staff. This poses as a potential health and safety risk.
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Written plan to be submitted to CCL by POC due date 5/5/2021.
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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4