486803815-12-2-2021-21-AS-HDBI-CB94EM-20220201180235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803815
Report Date: 12/02/2021
Date Signed: 12/02/2021 11:56:33 AM

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
11/15/2021 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20211115114557

FACILITY NAME:	AMERICAN ASSISTED LIVING		FACILITY NUMBER:	486803815
ADMINISTRATOR:	SANDHU, SUKHJIT		FACILITY TYPE:	740
ADDRESS:	405 KINGS WAY		TELEPHONE:	(510) 604-3825
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	30	CENSUS: 15	DATE:	12/02/2021
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Eugenie Broussard		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not answer communications promptly and appropriately to the resident's representatives.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this date Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of delivering the findings for complaint # 21-AS-20211115114557, regarding the above-mentioned allegations, and met with Administrator, Eugenie Broussard. A risk assessment was completed with staff.

On 11/15/2021, the department received a complaint alleging the following: Facility does not answer communications promptly and appropriately to the resident's representatives. LPA Walters opened the complaint on 11/22/2021. At that time, LPA toured the facility made observations, interviewed residents and staff, reviewed facility sign in sheet and gathered resident’s documentation. Based on the information received, the following determinations were made:

Continued on 9099 C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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 2

Control Number 21-AS-20211115114557

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: 12/02/2021

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 9099

Interviews and Resident documentation revealed that the facility staff are appropriately communicating with responsible parties. Also, LPA did not find any information that shows the facility is failing to communicate promptly.

Based upon the information gathered through the investigation, we have found that the complaint alleging "Facility does not answer communications promptly and appropriately to the resident's representatives " is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited related to this complaint during today’s visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2