486803806-1-17-2023-21-AS-CMAZ-CN7SRF-20230118130615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 01/17/2023
Date Signed: 01/17/2023 09:58:45 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
08/29/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220829163730

FACILITY NAME:	VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE		FACILITY NUMBER:	486803806
ADMINISTRATOR:	DUNHAM, JOSEF		FACILITY TYPE:	740
ADDRESS:	3350 CHERRY HILLS COURT		TELEPHONE:	(707) 425-3588
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	250	CENSUS: 149	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rammy Kaur		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility did not provide adequate supervision resulting in an injury
Facility did not seek timely medical attention

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of closing this complaint. LPA met with Rammy Kaur and discussed the findings. This Department has investigated the allegations by conducting interviews and obtaining and reviewing documents. Based upon the documents and interviews, the following determinations are made: R1, who is a fall risk, required bathroom assistance and status checks; Care staff were aware of R1's status and checked on R1 at approximately 3:30 am on night of 08/27/2022; approximately 1 hour and 20 minutes later R1 was checked again and found to have fallen to the floor and sustained an injury; Staff immediately called 911 and remained with R1 until paramedics arrived. Although the allegations may be true, based upon the interviews and documents reviewed, there is not a preponderance of evidence to prove the allegations true or, not true. therefore, the allegations are UNSUBSTANTIATED.

Report left.
No citations issued today.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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