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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 11/03/2020
Date Signed: 11/06/2020 09:17:02 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
04/06/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200406153513
FACILITY NAME:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:HALL, JAMESFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:James HallTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff are not responding to residents pendents in a timely manor
INVESTIGATION FINDINGS:
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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold contacted Executive Director James Hall to deliver investigative findings for the above allegation. This visit is being conducted via telephone due to COVID-19 precautions. Based on interviews conducted and a review of call log records from March 25 through April 14 2020, the data showed a response time of 20-30 minutes 319 times, a response of 30 or more minutes 241 times and no response recorded 281 times during this time span. This accounting does not include calls that were responded to under the 20 minute response time. The logs record the time the alarm is activated, the time response is recorded and the staff member name responding. LPA conducted a review of the facility program plan and found the Residence and Care Agreement states that each apartment is equipped with an emergency call system and is monitored 24 hours a day. The Program plan states that should a resident show any sign or symptom of distress.... Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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-20200406153513
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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 11/03/2020
NARRATIVE
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...Continued from LIC 9099...
Emergency medical services will immediately be summoned. A delay of 20 or more minutes, some calls for service being activated numerous times without a response, does not meet the response outlined in the residence care agreement.

Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


This report was reviewed with Executive Director and Appeal rights were given.

Original Signature on file.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
04/06/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200406153513

FACILITY NAME:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:HALL, JAMESFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff are not showering resident
INVESTIGATION FINDINGS:
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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold contacted Executive Director James Hall to deliver investigative findings for the above allegation. This visit is being conducted via telephone due to COVID-19 precautions. Based on interviews conducted and a review of records, Residents are provided with certain days on which showers are provided. Facility documents when the shower is provided or if it is refused. The documents are reviewed by the Health and Wellness director and if a resident refuses often, a care plan meeting is conducted to address the issue. The resident shower documentation reviewed showed showers were provided.
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.
Original Signature on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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 4
Control Number 21-AS-20200406153513
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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2020
Section Cited
CCR
87208(a)(2)
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87208(a)(2)Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation. (2) A copy of the Admission Agreement, containing basic and optional services. This
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Licensee to ensure resident assistance is provided in a timely manner. Licensee to draft a policy regarding calls for assistance by residents and ensure all staff are trained on the policy. Licensee to
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requirement is not met as evidence by: Based on a review of records and interviews, Licensee did not follow program plan as shown by call button logs. This poses an immediate Health and safety risk for residents in care.
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submit the policy to CCL by POC date of 11/04/2020. Licensee to submit signed staff training logs to verify staff training to CCL by POC date of 12/01/2020.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4