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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 10/27/2021
Date Signed: 11/12/2021 11:01:22 AM

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: 145DATE:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kayla Young, Assistant Executive Director; Kelli Roe, Operations Coordinator; Meri Vejar, Regional Director of Health and WellnessTIME COMPLETED:
04:00 PM
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Licensing Program Analyst Jill Nakagawa met with Kayla Young, Assistant Executive Director; Kelli Roe, Operations Coordinator; Meri Vejar, Regional Director of Health and Wellness for a case management visit.

Facility self reported on 10/26/21 R1 attempted self-injury. R1 was found by caregiver with stocking tied to neck and the grab bar in bathroom. Facility immediately contacted 911; R1 was taken to hospital on a 5150. Per 602, R1 had a diagnosis of "Bipolar" but was able to live in independent living. LPA conducted interviews with Nurse Meri Vejar and reviewed documentation.

Documentation requested:
602
Med List
Care Plan


No citations for deficiencies issued at this time
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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