486803806-2-17-2022-21-AS-KMOA-CBXMU5-20220224085430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:29:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220111161722

FACILITY NAME:	VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE		FACILITY NUMBER:	486803806
ADMINISTRATOR:	MALIK, NOMA		FACILITY TYPE:	740
ADDRESS:	3350 CHERRY HILLS COURT		TELEPHONE:	(707) 425-3588
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	250	CENSUS: 140	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jillian Hunter		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident handled roughly
Neglect/Lack of supervision resulting in unwitnessed fall

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of continuing the investigation of this complaint. LPA toured portions of the facility and took additional statements from residents. LPA met with Executive Director and delivered findings. Based upon interviews and documents, the following determination are made: R1 has sustained injuries and bruising from falls occurring at the facility; R1 has medical conditions that put R1 at high risk for falls and injuries; R1 has fallen on many occasions; Facility records indicate fall protocols have been followed by staff and R1's personal physician indicates that R1 is not a candidate for pendant call device; R1 and family member state that R1 receives good care and that staff care for R1 appropriately; Outside professionals state that R1 receives appropriate care at the facility; No witnesses to alleged rough handling of R1 have been identified. While the allegations may be true, based upon the statements made and documents reviewed, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, the allegations are UNSUBSTANTIATED.

No citations issued today. Report left at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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