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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 02/24/2022
Date Signed: 02/25/2022 12:34:31 PM



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
09/10/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20210910085402
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:
02/24/2022
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Acting Administrator, Jillian HunterTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident in care
Neglect/Lack of Supervision resulting in resident sustaining multiple injuries
INVESTIGATION FINDINGS:
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Licensing Program Analysts Felias and Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Acting Administrator, Jillian Hunter

The complaint alleges that staff did not seek timely medical care for resident in care and Neglect/Lack of Supervision resulting in resident sustaining multiple injuries. Based on interviews with staff, residents, outside parties and a review of medical records, the investigation showed that on 8/28/2021, Resident (R1) was found in a sitting position after pressing their call pendant due to a fall in R1’s room. Record review revealed that it took approximately 35 minutes for staff to respond to the call for help. A further review of facility records show that staff have been trained to call 911 for a resident who falls and is on a blood thinner. This did not take place when R1 fell.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
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
Control Number 21-AS-20210910085402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2022
NARRATIVE
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Continued from LIC9099

During a separate incident, R1 was found unresponsive on 9/2/2021 at the facility and was then taken to the hospital for medical care where R1 was observed to have bruising on the left inguinal (outer left hip) area and ecchymosis at the umbilical area. In addition, medical records for R1 identified and photographed a bilateral pressure injury on R1’s buttock after being admitted to the emergency department after being found unresponsive on 9/2/2021. Staff (S1) did state they were aware of a pressure injury on R1’s buttocks but did not document nor report it because S1 saw “white cream” on it which S1 believed the Med Techs were using to treat it. Interviews with Med Techs, Nurses and supervisors all stated they were unaware of the pressure injuries on R1’s body. Facility records show no documentation of R1 having a pre-existing pressure injury upon admittance at the facility.
Based on the departments record review, interviews with staff and outside parties the allegations that Staff did not seek timely medical care for resident in care and Neglect/Lack of Supervision resulting in resident sustaining multiple injuries are substantiated. The preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED.

An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1548(d).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal Rights given. Signatures on file.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20210910085402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2022
Section Cited
HSC
1569.269(a)(6)
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§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This
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Facility agrees to have an in-service for all caregivers and Medication Technicians regarding protocol on reporting changes of condition no later than 3/72022. Acting Administrator agrees to submit planned training date(s) and what subjects will be trained no later than POC due date, 2/26/2022
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requirement was not met based on interviews and documents that show that facility did not seek timely medical care for resident, R1. This is an immediate risk to health and safety of residents in care.
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An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1548(d).
Type A
02/26/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. Licensee shall ensure that residents are...observed for changes in physical,mental,emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes...or deterioration of mental ability or a physical health condition are observed, licensee shall ensure that such
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Facility agrees to have an in-service for all caregivers and Medication Technicians regarding how to observe residents for changes in condition no later than 3/72022. Acting Administrator agrees to submit planned training date(s) and what subjects will be trained no later that POC due date, 2/26/2022
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changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement wasn't met based on interviews & documents that show that some staff didn't observe bruising or pressure injury on R1 despite assisting with care & some observed injuries but didn't report. This is an immediate risk.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3