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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 05/03/2021
Date Signed: 05/04/2021 02:07:40 PM



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
04/14/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210414151114
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: 133DATE:
05/03/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kayla Young/Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not respond to resident's call for help
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Kayla Young, Assistant Administrator, for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the Covid-19 precautions. The LPA did not physically present at the site. This investigation included interviews with witnesses; staff; and parties, as well as records and documents reviews. The following determinations were made: On or about April 13, 2021, R1 called front desk following a fall; Front desk did not respond to R1's call or subsequent initial call from R1's family member and R1 did not obtain assistance for approximately 20 to 30 minutes. Based upon the documents and records reviewed and statements taken from witnesses, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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 3
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
04/14/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210414151114

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: 133DATE:
05/03/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kayla Young/Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Lack of sufficient staff results in inadequate front desk coverage
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Kayla Young, Assistant Administrator, for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the Covid-19 precautions. The LPA did not physically present at the site. This investigation included interviews with witnesses; staff; and parties, as well as records and documents reviews. The following determinations were made: A slow response to a resident’s call for help to the front desk has raised concerns of insufficient staffing at the front desk; A resident who fell on 4/13 was not wearing the pendant meant to summon help following a fall; The resident did phone the front desk but was not answered; Records indicate the front desk is staffed during and above business hours and covered by others on call staff during off hours; There are differing opinions as to whether or not the front desk staffing is sufficient to meet the residents’ needs; Administration took remedial action with the individual staff person identified as not responding to the resident’s call when the staff had the responsibility to respond. Based upon the statements taken and the documents reviewed, there is not a preponderance of evidence to prove the allegation is, or is not, valid. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20210414151114
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: 05/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2021
Section Cited
HSC
1569.269
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1569.269 H&S (a)(6) Residents of residential care facility for the elderly shall have all of the following rights: (6) to care, supervision, and services that meet their individual needs..delivered by staff ..in sufficient numbers, qualifications, and competency to meet their needs. ***Based upon statements and reviewed records,

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 Disciplinary action has been taken with the staff involved. Administration will submit a written plan that outlines protocols put in place that will prevent the future occurrence of front desk failure to respond to residents calls in a timely manner. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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this requirement has not been met as evidenced by: Front desk staff did not respond to R1’s call for help in a timely way following a fall. This posed an immediate risk to safety and health of resident in care.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
LIC9099 (FAS) - (06/04)
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