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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 11/21/2022
Date Signed: 11/21/2022 11:29:33 AM


Document Has Been Signed on 11/21/2022 11:29 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:RAMANDEEP KAURFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 150DATE:
11/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Ramandeep KaurTIME COMPLETED:
12:00 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
Licensing Program Analyst (LPA), Farhaan Sarangi and Fairfield Fire Department Inspector, Bryan Just arrived unannounced at Village at Rancho Solano Assisted Living, The for the purpose of conducting a Case Management-Other inspection. LPA and Fire Inspector met with Administrator, Ramandeep Kaur.

LPA, Administrator and the Fire Inspector toured the second floor of the Memory Care Unit. During the inspection, Fire Inspector notified the facility and the LPA that the Fire Alarm system is completely down for the building. Furthermore, the STD 850 has been denied for the second floor Memory Care Unit. During the tour, LPA and Fire Inspector observed residents residing in the 2nd floor Memory Care Unit. Fire Clearance has not been approved for the 2nd Floor Memory Care Unit (See LIC 809D-Civil Penalty Assessed). LPA and Fire Inspector requested the following documents today:

-LIC 500
-Staff Roster for Memory Care Units on the first and second floor

LPA requested the following document(s) by December 1, 2022:

In Depth Descriptive Fire Watch indicating who will be additional staff and education on the fire watch. In addition, Descriptive Fire Watch plan will be due to the State of California-Department of Social Services-Community Care Licensing Division and Fairfield Fire Department by December 1, 2022.

Deficiencies and Civil Penalty are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights was given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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 11/21/2022 11:29 AM - 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: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited

1
2
3
4
5
6
7
87202 Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

(1) Nonambulatory persons.
(2) Bedridden persons
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Based on observation of the STD 850, the fire clearance was not approved due to the Fire Alarm system being inoperable during the inspection with the Fairfield Fire Department. In addition, during the tour, LPA and Fire Inspector observed 16-24 residents in the Memory Care Unit on the 2nd floor that was not Fire Clearance approved.
8
9
10
11
12
13
14
In addition, Descriptive Fire Watch plan will be due to the State of California-Department of Social Services-Community Care Licensing and Fairfield Fire Department by December 1, 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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2