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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803688
Report Date: 09/09/2021
Date Signed: 09/14/2021 09:06:08 AM

Substantiated


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
04/27/2021 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20210427100823
FACILITY NAME:SOLANO QUALITY HOME CAREFACILITY NUMBER:
486803688
ADMINISTRATOR:PRAKASH, SNEH LATAFACILITY TYPE:
740
ADDRESS:266 DE SOTO DRIVETELEPHONE:
(707) 386-3600
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 3DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Sneh Lata PrakashTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility staff did not seek medical attention for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Solano Quality Care Home for the purpose of amending the complaint report due to a typographical error found in the body of the investigation. LPA met with Administrator, Sneh Prakash, and was granted access into the facility.

During the investigation, the Department conducted interviews with staff, medical professionals and other involved parties, made observations and reviewed documents. Based on multiple interviews and a review of various documents the Department learned that Resident, R1 had an unwitnessed fall and reported to the Administrator that her hip was hurting on 11/08/2020. Administrator gave pain medication to R1. Furthermore, R1 was not sent to the hospital until 11/09/2020 at which time the attending physician diagnosed R1 with a fractured pelvis. According to interviews, staff noted R1 complained of pain, yet medical attention was not sought. Interviews with the Administrator noted that resident complained of pain on the day after following the unwitnessed fall. Based on documentation and statements interviewed individuals, it was concluded that the residents fall, and complaint of hip pain occurred on 11/08/2020 and medical attention was not sought until 11/09/2020. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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 5
Control Number 21-AS-20210427100823
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: SOLANO QUALITY HOME CARE
FACILITY NUMBER: 486803688
VISIT DATE: 09/09/2021
NARRATIVE
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R1's responsible party was notified of the hip pain and the Administrator requested the Responsible Party to schedule a medical appointment. Interview with R1's responsible party indicated that they did receive notification from the facility at the time of the Change of Condition.

The Department has determined that the allegation that facility failed to seek timely medical attention for resident is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of client’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Exit interview conducted, appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20210427100823
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: SOLANO QUALITY HOME CARE
FACILITY NUMBER: 486803688
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/10/2021
Section Cited
CCR
87466
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87466: Observation of the Resident. Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of mental ability or a physical health condition are observed, Licensee shall
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Administrator agrees to schedule training with an approved outside vendor for all care staff with for all staff regarding observation of a residents. Plan for training to be submitted to CCL by POC due date. Proof of training including trainer, topics covered, date and time spent and attendees to be submitted by September 17, 2021.

Additionally, Administrator will provide company protocol outlining how residents are observed for changes and how those changes are reported to management.
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ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement is not met as evidenced by: Based on interviews it was determined that staff observed a change of condition in 1 of 1 resident (R1) but didn't notify R1s physician which poses an immediate health and safety risk to residents.
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“An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of client’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.”

Facility agrees to submit self-certification that designated staff has read, understand and will follow regulation and the facility policy surrounding observing changes in residents and notifying their responsible party by POC due date.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
04/27/2021 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20210427100823

FACILITY NAME:SOLANO QUALITY HOME CAREFACILITY NUMBER:
486803688
ADMINISTRATOR:PRAKASH, SNEH LATAFACILITY TYPE:
740
ADDRESS:266 DE SOTO DRIVETELEPHONE:
(707) 386-3600
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 3DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Sneh Lata PrakashTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff neglect resulted in resident sustaining fractures in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Solano Quality Care Home for the purpose of delivering complaint findings. LPA met with Administrator, Sneh Prakash, and was granted access into the facility.

During the investigation, the Department conducted interviews with staff, medical professionals and other involved parties, made observations and reviewed documents. Interviews yielded that there was no indication that R1 sustained a fall. At the time the injury occurred, R1 was not a fall risk and was ambulatory. Staff reported no witnessed falls and instead said that R1 might have “plopped” down when she sat down. On 02/16/2021, R1 suffered a fall and fractured her left hip. R1 fell in a common area and did not require 1 on 1 care. R1 used a walker and was assisted in and out of bed and to the bathroom. Staff followed fall procedures and policies by ensuring that R1 utilizes a walker and being assisted while walking.

This agency has investigated the above allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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 5
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
04/27/2021 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20210427100823

FACILITY NAME:SOLANO QUALITY HOME CAREFACILITY NUMBER:
486803688
ADMINISTRATOR:PRAKASH, SNEH LATAFACILITY TYPE:
740
ADDRESS:266 DE SOTO DRIVETELEPHONE:
(707) 386-3600
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 3DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Sneh Lata PrakashTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility staff are not dispensing medication as prescribed by physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Solano Quality Care Home for the purpose of delivering complaint findings. LPA met with Administrator, Sneh Prakash, and was granted access into the facility.

During the investigation, the Department conducted interviews with staff, medical professionals and other involved parties, made observations and reviewed documents. A review of the Medication Assessment Record (MAR), Physician Orders and Hospice Agency nursing notes indicate that R1 did receive medication in an appropriate manner consistent with Doctors orders.

Based on LPAs observations, record reviews, interviews with staff, and conflicting information obtained from other related party(s) there is insufficient information to prove or disprove the allegation of, Facility staff not dispensing medication as prescribed by physician. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5