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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 11/03/2021
Date Signed: 11/03/2021 01:47:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:MALIK, NOMAFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 128DATE:
11/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Meri Vejar, Regional Director TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA Cuadra arrived unannounced to conduct a case management visit and met with Meri Vejar, Regional Director of Health/Wellness and Roschelle Factor LVN/HWD. LPA is following up regarding five incident report received on 10/20/21, 10/25/21, 10/26/21 and a SOC341 received on 11/01/21.

On 10/20/21 facility reported an incident that occurred on 10/17/21 approximately 6:15pm when resident (R1) pressed their pendant and was found on the floor next to their bedroom door. R1 stated that they were trying to take their pants off to get ready for bed when they lost balance and fell. R1 complained of right hip pain and staff contacted 911 to transport R1 to Northbay Medical Center. Responsible parties were notified. Facility was notified by responsible party that R1 underwent hip surgery and will be transferred to a skilled nursing facility for rehabilitation therapy. Facility will re-assess resident prior to return to the facility and modify care plan accordingly. Per Meri, R1 is currently in rehabilitation therapy at Fairfield Post-acute.


LPA followed up on incident report submitted to CCL on 10/20/21 involving resident (R2). On 10/5/21 resident (R2) was placed on hospice services when a medication order for Carbidopa-Levodopa 25-100mg was transcribed with the incorrect dose by facility staff (S1). The incident was discovered on 10/9/21 when med-tech (S2) attempted to re-order medication Carbidopa-Levodopa 25-100mg from Kaiser pharmacy for resident (R2). S1 was told it was too soon for refill, so S2 then checked the order and found a discrepancy in what was ordered versus what had been given to R2, as soon as noticed S2 notified their supervisor. Supervisor verified the EMAR system and found that R2 was provided with the incorrect dose due to transcription error, med-tech wrote 1.5 tab three times a day of Carbidopa-Levodopa 25-100mg in words instead of one-half tab three times a day in numbers as prescribed by doctor. Supervisor submitted a fax request for clarification to R2’s primary physician and responsible party were notified. Medication direction was clarified on 10/13/21 and facility MAR was updated. On 10/20/21 R2 and facility staff participated in a neuro psychiatrist tele appointment to review incident, and it was agreed for R2 to continue Sinemet 1 tab three times a day. Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/03/2021
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Continued from LIC809...
After this incident a new process called "3 step process" was initiated on 10/13/21 by the facility to verify all medication orders, document any changes and notify supervisor immediately for any discrepancies prior to giving medications to residents in care. All med-tech and facility nurses received 8 hour annual medication management training. During today's visit LPA was provided with proof of medication training for staff following medication errors conducted on 10/6/21, 10/13/21 and 10/20/2021.


Two incident reports were submitted to CCL on 10/28/21 involving resident (R3) who on 10/25/21 at approximately 4:00pm while resident was in a common area started to shake uncontrollably with foaming in their mouth, staff contacted 911 and R3 was transported to Northbay Medical Center, responsible parties were notified. R3 was diagnosed with an episode of shaking and advanced dementia. R3 returned to the facility and a hospice evaluation was scheduled. On 10/26/21 at approximately 1:40am R3 was found on floor face down after being checked 5 minutes before, bleeding and discoloration was noted on their left eye, 911 was contacted and was transported to the Hospital. Also, responsible parties were notified, R3 was discharged the same day with a diagnosis of acute head injury, advanced dementia and fall from ground level. Facility continued to frequent safety checks to R3 a fall mat was placed and bed was placed on lowest position. During today's visit LPA observed R3's bed to make sure that resident was not being restrained in any way. LPA was informed that currently R3 is receiving hospice services due to their health has been declining and observed that R3 has a bed that was provided by hospice that doesn't restrain resident.

LPA followed up on self-report incident was received on 11/1/21 along with a SOC341 alleging suspected physical abuse involving resident (R4) who on 10/29/21 at approximately 18:00 caregiver (S3) reported that while providing care to R4 became aggressive and grabbed their wrist, S1 yelled out in pain and startled resident. S1 reported the incident to a supervisor and mentioned that they had hurt their wrist earlier and was sent out to a local clinic for evaluation. R4 resides with their partner (R5) in the facility, R4 had been showing behaviors and fear of people providing services including hospice. Shortly after this incident happened, the facility received a call from R4's responsible party reporting that they received a call from R5 reporting that someone had hit R4. Facility immediately began investigation, but there were no physical signs of abuse observed by staff, R4's doctor was notified and UTI test was performed. During today's visit, LPA conducted confidential interviews with residents, reviewed records and made observations, facility conducted in-service training to all staff about Mandated Reporting and Elder Abuse on 9/28/21 and 9/30/21.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2021
Section Cited

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87465-Incidental Medical & Dental Care Services...shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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Based on records review and interviews conducted with facility staff, the med tech (S1) did not transcribe the correct dosage to R2; R2 was given 1.5 pill of Carbidopa-Levodopa 3x/day instead of 1 tab 3x/day as ordered/prescribed by the Physician from 10/ to 10/9/21 which poses an immediate risk to the health and safety of residents 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3