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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 09/23/2021
Date Signed: 09/23/2021 11:30:49 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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 David Leibert
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: 138DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Noma MalikTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not attend to resident's pendant call in a timely manner
Facility did not notify licensing agency of resident's incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Noma Malik and discussed the findings. R1 suffered unwitnessed fall on 8/28/2021 and summoned help with emergency response system. The Response Time Report indicates a 35 minutes and 48 seconds response time to R1's call. The Report for month of August 2021 indicates 27 out of 180 responses exceeded 30 minutes and 3 responses exceeded 50 minutes. The Program Plan and Care Agreement state that each apartment is equipped with an emergency call system and is monitored 24 hours a day. The Program plan states that should a resident show any sign or symptom of distress emergency medical services will immediately be summoned. A delay of 30 or more minutes, does not meet the response outlined in the residence care agreement. The facilities Clinical View Report indicates staff noted bruising on R1 on 8/29/21 and on 9/1/21, although R1 was not complaining of pain. Following R1's fall which resulted in serious injury according to SOC341 of 9/10/2021 and verified by photographs taken 9/2/21 and 9/8/21, facility failed to report the incident to Licensing Agency until 9/10/2021 when requested to do so by Licensing Agency. ***Continued page two***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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, 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: 09/23/2021
NARRATIVE
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Based upon the statements taken, documents reviewed, and photographs observed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED.

9099© The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Civil Penalty issued in the amount of $250.00 for a repeat violation within 12 months.

SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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, 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: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2021
Section Cited
CCR
87208(a)(2)
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87208(a)(2) PLAN OF OPERATION. Each facility shall have and maintain a current, written definitive plan of operation. (2) A copy of the Admission Agreement, containing basic and optional services. ***This requirement is not met as evidence by: Based on a review of records and interviews,
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Licensee to ensure resident assistance is provided in a timely manner. Licensee to draft a policy regarding calls for assistance by residents and ensure all staff are trained on the policy. Licensee to submit the policy to CCL by POC date. Licensee to submit signed staff training logs to verify staff training to CCL in order to clear the deficiency by 10/04/2021.
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, Licensee did not follow program plan as shown by call button logs. This poses an immediate Health and safety risk for residents in care. **Civil penalty issued in the amount of $250.00 for repeat violation within 12 months.

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Type B
10/04/2021
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) REPORTING REQUIREMENTS. ..Licensee shall report to the Department…within 7 days..Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. ***Based upon documents reviewed, statements, and photographs, this
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Facility will train all staff on the reporting requirements of 87211. Outline of proposed training due by POC with training completion proof to follow in order to clear the deficiency.

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requirement not met as evidenced by: Facility did not report timely R1’s fall which resulted in injury and bruising. This posed an immediate risk to health and safety of resident.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
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