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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 06/22/2021
Date Signed: 06/22/2021 05:19:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 17DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Eugenie Broussard, Facility ManagerTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Katrina Walters and Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection at this facility and met with Facility Manager, Eugenie Broussard (EB). The facility administrator, Sandhu, Sukijit (SS), arrived later. At the time of inspection, there were 3 staff and 1 facility manager providing care and supervision for 17 residents.

LPAs arrived at the facility and observed missing screen on one of the front windows. Per, EB and SS window screens fell of after a recent windstorm. A sanitization station was in the break room/side entrance. Facility manager EB agreed to move it to the front entrance; to include the sign-in binder, including screening questions, and the temperature gun; to be used by staff and visitors. LPAs and facility manager (EB) toured the facility at approximately 10:15 am. LPAs observed that staff were wearing face masks. Residents were socially distanced in the living room. Other residents were resting in their rooms. Per Facility Manager (EB), residents are monitored for symptoms daily. Residents’ medications are stored and locked in the Medication Room. Facility has a 30-day supply of medication for residents. Facility has submitted a mitigation program plan. LPAs are requesting that some modifications be made to the mitigation plan and sent to CCL. Postings pertaining to COVID-19 were throughout the facility. Facility has PPE supply stored in a closet in the staff lounge.

Continued on to 809 C

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/22/2021
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Continued from 809

LPAs and Facility Manager (EB) toured resident bedrooms and found 6 out of 15 to be without fitted sheets on the beds.(pictures taken) Per administrator, the dryer had been broken but was fixed the day prior and they were still catching up on laundry. LPAs observed that auditory alarms in the front door, dining room, kitchen door from main hallway and the door leading to the entertainment room were not active. EB was present and upon learning of issue, had staff activate auditory alarms on the doors; Administrator (SS) added alarms to doors that were missing alarms or whose alarms were not functioning properly. Based on record review there were at least two residents present who have dementia and are a wandering risk. While touring the outside of building, three gates that are listed as emergency EXITS on the facility sketch were observed to be locked with a variety of materials (phone cord, bike lock, etc.)(pictures on file) Administrator (SS) agreed to remove locks and mentioned that there would be a meeting with the Fire Department the following week to discuss their options. In addition, the Administrator agreed to develop a plan for cleaning and disinfection for the facility, as well as placing hand soap dispensers in all of the resident bathrooms. Administrator will have staff fit tested for N95 mask. LPA provided Administrator with a copy of PIN 21-10.


California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC- 809D. Exit interview conducted with Facility Manager, Eugenie Broussard, Appeal Rights provided. LPA provided EB with a copy of the report. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Immediate civil penalty of $1000 assessed as this is an immediate and repeat violation of same subsection within the past 12 months.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203


This requirement is not met as evidenced by: This requirement is not met as evidenced by: 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in 3 out of 5 facility emergency exits were locked which poses an immediate health, safety or personal rights risk to persons in care.
**Immediate Civil Penalty assessed in the amount of $1000
POC Due Date: 06/23/2021
Plan of Correction
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Licensee removed locks from facility exits during facility visit. Licensee will develop a plan with the fire department and submit plan to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)


This requirement is not met as evidenced by: 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:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 5 out of 14 door alarms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2021
Plan of Correction
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Licensee is to ensure that staff are checking to ensure auditory alarms on doors are active at all times. Licensee to submit a copy of the staff's check off sheet, indicating that they are checking to ensure auditory alarms are turned on and send proof to LPA Walters by POC due date.
Type B
Section Cited
CCR
81088(j)(4)

81088(i)(4)Fixtures, Furniture, Equipment and Supplies. The licensee shall ensure that each client has clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary;bath towels, hand towels&washcloths. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & Interviews the licensee did not comply with the section cited above in 6 out of 15 residents beds were not outfitted with mattress pads and fitted sheets which poses a potential health risk to clients in care.
POC Due Date: 06/25/2021
Plan of Correction
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Licensee to ensure that all residents beds have all necessary bedding including matress pads as per Title 22 regulations. Licensee to submit pictures to CCL attention LPA Walters as proof of correction by POC date of 6/25/2021.
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: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4