486803806-12-15-2022-21-AS-FSAI-CM5S3J-20221215123112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:32:43 PM

Document Has Been Signed on 12/15/2022 12:32 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, THE		FACILITY NUMBER:	486803806
ADMINISTRATOR:	RAMANDEEP KAUR		FACILITY TYPE:	740
ADDRESS:	3350 CHERRY HILLS COURT		TELEPHONE:	(707) 425-3588
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	250	CENSUS: 152	DATE:	12/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator, Ramandeep Kaur		TIME COMPLETED:	12:45 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 arrived unannounced at Village at Rancho Solano Assisted Living, The for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Ramandeep Kaur, and was granted access into the facility. LPA and Administrator toured the facility and found the facility to be clean and at comfortable temperature. Exits and pathways were free from obstructions. Fire extinguisher were last serviced on October 2022. Facility is currently on a Fire Watch plan due to the Fire Alarm system not working with the expected replacement in Mid-January. Fire Watch is in place and was approved by Fairfield Fire Department on December 14, 2022. Hot water temperature measured within regulation of 105 to 120 degrees F. Bathrooms contained necessary grab bars and non-slip floors. During the tour, LPA observed residents being served meals. Food was found to be stored in a safe manner and appropriately labeled. Kitchen staff are aware of resident dietary restrictions. LPA toured the Memory Care Unit. Medications were centrally stored and locked. Toxins are stored in the garage. Hazardous items were also kept inaccessible and locked. There was a supply of cleaners, hygiene products and paper products available for residents. First aid kit was found to be appropriate at the time of the inspection. Elevator were last inspected on August 9, 2019 with an expiration bearing August 9, 2020 (See LIC 809D). Administrator shared that the elevators should be inspected every single year, but was not inspected last year. Facility understands that resident’s beds must be outfitted with mattress pads as required by Title 22 Regulations # 87307. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored on the outside of the 2nd floor Memory Care section of the facility in the storage room. Staff have had all PPE training required and have been N95 Fit tested, but not recertified. LPA requested the following documents to be sent to CCL: (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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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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
	VISIT DATE: 12/15/2022

NARRATIVE

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LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Carbon Monoxide Detector testing date document(s)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

LPA already obtained a copy of the LIC 610E (Emergency Disaster Plan) and Fire Watch Plan on December 14, 2022.

Deficiencies 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 repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights was emailed along with this report.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/15/2022 12:32 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: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 3 out of 3 elevators that were last inspected on August 9, 2019 with an expiration of August 9, 2020 which poses a potential health, safety or personal rights risk to persons in care. In addition, this regulation poses a potential risk to visitors and staff members.
	POC Due Date: 01/04/2023
	Plan of Correction
1 2 3 4	Plan of Correction (POC) shall include a written statement on how future compliance will be met. In addition, provide proof that the 3 out of 3 elevators will be inspected by the POC due date. Administrator requested an Extention for the POC due to the holidays.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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