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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 01/27/2025
Date Signed: 01/27/2025 03:33:20 PM

Substantiated


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
01/13/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250113110424
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 24DATE:
01/27/2025
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Sukhjit Sandhu, Licensee/AdministratorTIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Lack of supervision resulting in elopement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived at American Assisted Living facility on 01/27/2025 to conclude an investigation and deliver findings regarding the above allegation. LPA met with the Licensee/Administrator Sukhjit Sandhu.

During the course of the investigation, LPA toured the facility, made observations, conducted interviews with staff and outside parties, reviewed records includig Suisun City Police Reports.

It is alleged that due to a Lack of Supervision Resulted in Elopement of a resident. The Department learned that resident (R1) eloped two times, 8/9/24 and 1/11/25. It was discovered that on 1/11/25 R1, who is wheelchair bound

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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-20250113110424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/27/2025
NARRATIVE
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Continued from 9099....

was able to exit the facility through a side gate and down the driveway. Interviews revealed that R1 was located approximately one (1) milefrom the facility without staff supervision rolling in their wheelchair in the roadway. It was reported by staff, that due to staff attending to another resident, they did not observe R1 exit the facility.

Based on interviews, statements received, records reviewed and LPA's observations, the preponderance of evidence standard has been met. Therefore, the above allegation that Lack of Supervision resulting in Elopement is SUBSTANTIATED.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Immediate Civil penalties are being assessed in the amount of $500 for lack of care and supervision of resident by facility staff.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250113110424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2025
Section Cited
CCR
87411(a)
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87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Licensee agreees to train staff regarding responsibility of providing supervision to residents not allowed to leave the facility unassisted, and send in proof of training by 01/28/2025. General Manager provided proof of staff training. POC cleared during visit.
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Based on LPA record review, and interview, Licensee did not provide supervision to R1 on two occasions. The absence of supervision is an immediate risk to the Health, Safety and Personal Rights of residents in care. ***A Civil Penalty of $500.00 is being assessed.
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Type B
01/27/2025
Section Cited
CCR
87211(b)
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Reporting Requirements(a)
(a) Each licensee shall furnish to Department may require..., the following:(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Licensee to review that all incidents have been reported and to submit a plan of how timely reporting will be submitted going forward by 1/28/2025.
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This is evidenced by: Outisde agencies reports document elopements on 8/11/24 and 1/11/25.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
01/13/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250113110424

FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR:SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:30CENSUS: 24DATE:
01/27/2025
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Sukhjit Sandhu, Licensee/AdministratorTIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Continued from 9099......

It is alleged Personal Rights are violated due to R1's personal belongings are missing. LPA interviewed R1 and asked if he had clothing missing. He said the facility had not lost any of his belongings. S1 stated that facility had provided R1 with clothing. On 01/27/2025 LPA inspected R1's room and observed clothing in R1's drawer and a large hamper full of clothes and shoes belonging to R1. Based on interviews conducted, review of observations made, this allegation is Unsubstantiated.

A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4