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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:32:42 AM

Unsubstantiated


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
07/12/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220712110529
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: 153DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pam HardestyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulted in resident sustaining multiple fractures while in care
Staff pushed resident
Staff falsified incident reports
Staff are not providing adequate food service to residents
Staff are not meeting residents hygiene needs
Staff are not wearing masks
INVESTIGATION FINDINGS:
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LPA Leibert arrived unannounced and met with Pam Hardesty to discuss findings on this complaint. This Department investigated the allegations by making site visits, taking statements, reviewing documents and photographs. The following determinations are made: Statements and documents suggest that R1's fall was not the result of staff neglect and there is conflicting statements regarding the allegation staff pushed R1; Complainant has not responded to this Department's request for information regarding the false reporting allegation; Documents and statements indicate that R1 frequently refused staff's attempt to provide hygiene care and showers; Reviews of facility's menus and discussions with witnesses suggests that the food service at the facility meets the requirements of Title Twenty-Two regulations; There are differing opinions regarding the staff's compliance with requirements to wear masks; At every unannounced site visit to the facility, staff and visitors were observed to comply with the masking mandate. Although the allegations may be true, or valid, based upon the statements, site visits, documents reviewed, there is not a preponderance of evidence to support the allegations. Therefore, the allegations are UNSUBSTANTIATED.
Report left at facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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 3
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
07/12/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220712110529

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: 153DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pam HardestyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are Staff are not cleaning resident’s room
Staff not giving proper notice on increase in rent
Staff are not changing resident’s linen

INVESTIGATION FINDINGS:
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LPA Leibert arrived unannounced and met with Pam Hardesty to discuss findings on this complaint. This Department investigated the allegations by making site visits, taking statements, reviewing documents and photographs. The following determinations are made: R1 was sent out following a fall with injury on or about 07/06/2022; On or about 07/11/2022, R1’s bedroom was observed to be dirty from feces, including the bed linens and floors which appear to have occurred during the incident of 07/06/2022; Facility has not produced documentation to support compliance with R1’s Admission Agreement which requires written advanced notice of rent increases and has offered to refunded to R1 over $11,000.00 for liability waiver since the initiation of this complaint. Based upon the statements taken and photographs and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. 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. Report left at facility.
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: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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 3
Control Number 21-AS-20220712110529
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: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. ***This requirement not met as evidenced by: Based on photo’s and statements, R1’s room was observed to be dirty from feces, including floor and bedding. This posed an immediate risk to health of resident.
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Administration to submit to CCL by POC date a written plan to addresses how facility will provide sufficient maintenance of residents’ rooms going forward in order to clear this deficiency.
Type B
11/08/2022
Section Cited
CCR
87507(f)
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87507(f) Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement…This requirement not met as evidenced by: Based on statements and documents, facility failed to provide notice of fee increased to R1 as specified in the Admission agreement.
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Administration will review the requirements of 87507 and submit to CCL a signed, dated declaration addressing how facility will comply with 87507 going forward. Declaration to be submitted by POC date in order to clear the deficiency.
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This posed a potential risk to the personal rights of R1.
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Type B
11/08/2022
Section Cited
CCR
87307(3)
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87307(3)(C) Personal Accommodations and Services. (Licensee shall provide) Clean linen, including blankets, bedspreads… ***This requirement has not been met as evidenced by: Based on statements and photos, R1 has not been provided adequate clean linens. This posed a potential risk to the health of R1.
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Administration shall provide a written plan addressing how facility will comply with 87307 going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3