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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:07:18 PM


Document Has Been Signed on 04/21/2022 03:07 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: DATE:
04/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Facility Representive, Blaine LyonsTIME COMPLETED:
03:17 PM
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At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management visit and met with facility representatives, Pamela Hardesty and Blaine Lyons.

LPA followed up regarding two special incident reports/SOC-341s.
The first report states that R1 became agitated after a family visit and was found by staff trying to choke herself. Emergency Personnel was called and Resident was sent out to the hospital for evaluation. Per conversation with Resident Care Coordinator (RCC), Karina Loera Medina, resident returned to the facility on 4/16/2022, but attempted again yesterday, 4/20/2022. Facility called Police to investigate and it was determined that an investigation would not be conducted. Facility determined that Resident should be re-evaluated and arranged an appointment with R1's Physician. Resident is currently back at the hospital with a one-to-one caregiver.

The second report states that R2 called their family stating that their caregiver from a third party agency had made sexual verbal comments towards them. Per conversation with RCC, caregiver from third party agency was removed from facility immediately and no longer works there. Facility has been ensuring that third party caregivers for Resident are female. Resident has been observed to be content with new caregivers and is well.

LPA also followed up regarding the status of the Change of Administrator. Per conversation, Blaine Lyons will be the Administrator for the facility and will be completing the needed documentation.

LPA requested Change of Administrator paperwork to be submitted to CCL by Close of Business on Friday, 4/29/2022.

No Deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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