486803815-7-31-2024-21-AS-KMOA-D7XLZV-20240808091230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:28:39 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20240626084453

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR:	SUKHJIT SANDHU		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 25	DATE:	07/31/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Mantu Sandhu, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Licensee did not ensure that a medical assessment was performed on resident prior to acceptance of resident

INVESTIGATION FINDINGS:

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On 7/31/2024, Licensing Program Analyst and Administrator, Mantu Sandhu met for an announced office meeting and delivered complaint investigation findings. LPA gathered resident documents during the course of the investigation.

Complaint alleges Licensee did not ensure that a medical assessment was performed on resident (R1) prior to acceptance of resident. Based upon a review of R1's records, it was found that R1's physician's report is on file dated 5/26/2024 prior to resident admission into the facility.

This agency has investigated the complaint allegation listed above. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiency cited.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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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