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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:25:27 PM


Document Has Been Signed on 02/25/2022 12:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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: 141DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jillian Hunter, Acting AdministratorTIME COMPLETED:
12:25 PM
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At approximately 10:00AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual required Inspection and met with Acting Administrator, Jillian Hunter. Health and Wellness Director, Karina Loera Medina, was unavailable during the visit. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPAs temperatures were checked and documented. LPAs conducted a walk-through of the facility and observed the following: Facility had COVID-19 and face mask posters throughout the facility including at the entry way and hand washing signs in the bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas and are checked twice a day. LPAs observed staff wearing masks during this visit. Staff are screened daily at the beginning of their shifts. Administrator confirmed that staff are trained to observe residents for COVID-19 symptoms, but does not know if temperatures are checked daily. Administrator will confirm with Health and Wellness Director if this is occurring. Residents are encouraged to wear masks while in common areas. Commonly touched surfaces are disinfected twice a day. LPAs confirmed that housekeeping works 7 days/week. Facility provides training on infection control and proper use of PPE.

LPAs and Administrator discussed resident activities and visitation.

Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves, gowns, and hand sanitizer.

Continued on LIC809-C.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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Document Has Been Signed on 02/25/2022 12:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(e)
Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Facility did not have the available record when requested by CCL. This poses a potential health and safety risk to residents in care.
POC Due Date: 03/01/2022
Plan of Correction
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Facility agrees to contact outside agency as soon as possible and will provide update to CCL no later than POC date of Tuesday, March 1, 2022. Facility will attempt to find missing file and if unable to will recreate file as much as they can.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 02/25/2022
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Continued from LIC809.

Fire Extinguishers were last serviced October 2021. Service logs for fire alarms and carbon monoxide detectors were serviced this month.

LPAs requested the following documents for current Administrator, Tommy Saxon, until Acting Administrator receives their Administrator Certificate:


  • Updated LIC308 (Designation of Facility Responsibility) with Licensee signature
  • Resume


LPAs requested a resident file that has gone missing. LPAs requested for specific documents from the file that Acting Administrator will obtain from an outside agency.

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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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