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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 09/02/2022
Date Signed: 09/02/2022 02:24:10 PM


Document Has Been Signed on 09/02/2022 02:24 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:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 155DATE:
09/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Francine TaitanoTIME COMPLETED:
02:40 PM
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
At approximately 12:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted by facility on 08/19/2022. LPA met with Assistant Executive Director Francine Taitano and reviewed records. The incident was a medication error. On 08/13/2022, Staff administered the wrong medication to resident. Facility contacted the primary care physician and responsible party and resident was placed on alert charting. There were no side effects from this incident.
***A civil penalty is being issued in the amount of $250 for this repeated violation within a 12 month month period.****

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

This report was reviewed with Francine Taitano and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/02/2022 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2022
Section Cited

1
2
3
4
5
6
7
87465(a)(5)-Incidental Medical and Dental Care:The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on
8
9
10
11
12
13
14
Self report made by facility, a staff member administered the wrong medication to R1. This is an immediate Health and Safety risk to the resident(s) in care. A civil penalty of $250 is being issued for this Repeated violation within in a 12 month period.
8
9
10
11
12
13
14
and counting medications. Licensee shall include a sign-in sheet. Plan to be submitted to CCL by POC date of 09/09/2022.

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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2