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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801928
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:59:00 PM


Document Has Been Signed on 09/14/2023 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:SOLANO LIFE HOUSEFACILITY NUMBER:
486801928
ADMINISTRATOR:FELIX, MARY E.FACILITY TYPE:
740
ADDRESS:575 S JEFFERSON ST.TELEPHONE:
(707) 678-1651
CITY:DIXONSTATE: CAZIP CODE:
95620
CAPACITY:38CENSUS: 27DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mary Felix, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management inspection and met with Administrator, Mary Felix.

LPA is following up regarding a self reported Incident Report that occurred on 9/11/2023. At approximately 1:15 PM R1 AWOLed from facility, and was located within 15 minutes at the nearby cemetery. A passerby called R1's sister who notified facility, who had already arrived on scene. R1 was assessed by staff, and there were no injuries. R1 had no complaints or concerns.

A review of facility cameras show that R1 had been watching deliveries being made and was able to push gate open due to gate not being properly latched. Administrator has posted new signage reminding delivery drivers to close gate and staff have been instructed to observe deliveries more closely, as well as keep an eye on R1 during deliveries and other times gate is opened.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and appeal of rights provided

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/14/2023 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SOLANO LIFE HOUSE
FACILITY NUMBER: 486801928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2023
Section Cited
CCR
87705(b)(2)

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering. This requirement was not met as evidenced by:
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Administrator agrees to conduct staff training regarding elopement, wandering and ensuring that all Memory Care Unit doors and gates are secured,
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Based on incident report the facility didn't comply with this section as R1 was allowed to leave facility on 9/11/23 which poses an immediate Health, Safety risk to residents in care.
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 and additional signage and alarms will be installed by 9/15/23.

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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: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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