<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 08/13/2021
Date Signed: 08/17/2021 04:15:50 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: DATE:
08/13/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Licensee, Sukhjit SandhuTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Hope Debenedetti, Licensing Program Analyst (LPA) Katrina Walters and Licensing Program Analyst, JIll Nakagawa made contact on this date, via Microsoft Teams, with Licensee, Sukhjit Sandhu and Administrator, Eugenie Broussard for the purpose of reviewing issues for Non-Compliance Conference. It is being conducted by tele-visit phone due to COVID - 19 precautions. LPA and LPM made subsequent phone call to deliver finalized reports with Licensee, which were e-mailed for signature.

Due to areas of concern identified by the Department, a Non-Compliance Conference was held. Verbal commitment from Licensee/Administrator was received for Non-Compliance plan during conference. Agreement to receive Technical Support assistance was agreed upon.

Non-Compliance Conference was held to discuss areas of concern including:
  • POCs not resolved and that are currently outstanding.
  • Resident retained with pressure injuries.
  • Insufficient care and supervision
  • Building and grounds
  • Auditory devices
  • Various physical plant concerns
  • Locked exits
  • Reporting requirements
  • Facilities future compliance.
Continued on 809 C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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 2
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: 08/13/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809

Licensee agreed to TSP service. Compliance Plan will be for two years.

No deficiencies cited during the Non-Compliance Conference
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2