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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:07:31 AM


Document Has Been Signed on 03/16/2022 11:07 AM - 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: 147DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Acting Administrator, Jillian HunterTIME COMPLETED:
11:17 AM
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At approximately 10:00AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Acting Administrator, Jillian Hunter.

Per review of incident report, Resident, R1, was seen walking on the street and returning back to the community. Per review of R1's LIC-602/Physician's Report, report indicated that resident was not diagnosed with dementia and did not have wandering behavior. Per interview with Acting Administrator, resident did not exhibit exit-seeking behavior prior to elopement. Following elopement, resident was reassessed and was moved to a higher level of care.

Per review of incident report, Resident, R2, reported pain and felt uncomfortable while receiving medical services from an outside agency. Facility reported incident to local police who are conducting their own investigation. Per conversation with Resident Services Coordinator, after incident, Facility had a staff member observe while resident received outside agency services. As of this week, resident is now receiving services previously provided by outside agency from their physician.


LPAs spoke with Acting Administrator regarding Change of Administrator. Acting Administrator provided LPAs with an updated LIC-500 and confirmed that VP of Operations/Administrator is present at the facility. Acting Administrator's certificate is in pending status and once approved will be processed by LPAs for Change of Administrator.

No Deficiencies cited during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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