<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:13:44 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
11/12/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20211112160418
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
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Jillian Hunter, Acting Administrator/Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Care: Staff did not call emergency services when resident sustained fractures
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts Willis and Felias arrived unannounced to deliver findings regarding the above allegation and met with Executive Director, Jillian Hunter.

Neglect/Lack of Care: Staff did not call emergency services when resident sustained fractures - Per facility self-report resident, R1 sustained a fall September 2020 and experienced discomfort in their knee. Hospice was notified approximately two hours after the fall and arrived at the facility approximately two hours after being called. Per interviews, R1’s pain increased while they were waiting for hospice to arrive, but the facility did not call (911) per direction from the resident’s family. Once hospice arrived it was reported that resident had a change of condition – increased pain and they could not stand or walk. 911 was then called and R1 was transported to the hospital.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20211112160418
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: 03/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099

An additional fall occurring February 2021 for R1 was self-reported by the facility. Per interview, resident’s fall was unwitnessed, and resident did not have any obvious injuries but did have a slight limp. The following day, resident was assessed by hospice and was able to move their extremities however, later the same day, R1’s family member reported to hospice that R1 was not able to move. A second call that day from the facility to hospice indicated that R1 was having additional pain. R1 was reassessed by hospice and sent to the emergency room. Staff interviewed revealed that, generally, hospice is called when a hospice resident sustains a fall unless the fall is severe. Per facility's "What to do when a fall occurs," document, if there is pain or bleeding, call 911.

The allegation Neglect/Lack of Care: Staff did not call emergency services when resident sustained fractures is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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 cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
11/12/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20211112160418

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
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Jillian Hunter, Acting Administrator/Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Care: Staff failed to call for emergency services when resident passed away
Facility failed to follow reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts Willis and Felias arrived unannounced to deliver findings regarding the above allegations and met with Executive Director, Jillian Hunter.

Neglect/Lack of Care: Staff failed to call for emergency services when resident passed away – Resident, R1 was receiving hospice services and had a A Physician Orders for Life-Sustaining Treatment (POLST) signed by their responsible party. The POLST indicated that cardiopulmonary resuscitation (CPR) was not to be attempted and that selective medical intervention treatments be considered. Per interview, facility staff reported that R1 was breathing slower and reported their observations to hospice. Hospice told staff to keep monitoring R1 and not to send them to the hospital. Staff continued to monitor resident. Resident passed away a couple of hours later and hospice was notified by staff. Per interview, staff was trained to contact hospice if residents are on hospice and have a DNR order. Per interviews and document review, hospice saw resident the day prior to them passing and were advised of breathing changes.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20211112160418
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: 03/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099A

The day resident passed, the facility called hospice and reported a general decline and shortness of breath. Staff were instructed to elevate resident and call hospice if conditions worsen. When hospice called the facility later, the facility reported resident having shallow respirations and unlabored breathing. Resident passed while facility staff was on the phone with hospice.

Facility failed to follow reporting requirements – Complaint alleges that staff did not notify the responsible party timely when R1 sustained a fall in September 2020. Facility reported that on the day of the fall, the resident’s family arrived at the facility for a routine visit within 30 minutes of the fall and the facility had not yet had the opportunity to call the family about the fall before they arrived at the facility.

This agency has investigated the complaints alleging Neglect/Lack of Care: Staff failed to call for emergency services when resident passed away and Facility failed to follow reporting requirements. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20211112160418
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: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2022
Section Cited
CCR
97465(g)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)
1
2
3
4
5
6
7
Facility has changed their policy to ensure 911 is called per regulation. Executive Director to conduct an inservice on regulation 87469- Advanced Directives and Requests Regarding Resuscitative Measures no later than March 25, 2022. Executive Director agrees to submit planned training date(s) to CCL by POC due date, 3/18/2022.
8
9
10
11
12
13
14
(4). This requirement has not been met as evidenced by interview and record review showing that 911 was not called for resident despite complaints of pain and inability to walk. This is an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5