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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 04/04/2023
Date Signed: 04/04/2023 01:44:47 PM


Document Has Been Signed on 04/04/2023 01:44 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:LAUREN COTTMANFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 155DATE:
04/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Administrators, Francine Tattiano and Lauren CottmanTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Village at Rancho Solano, The for the purpose of conducting a Case Management-Deficiencies inspection. LPA was greeted at the door by Assistant Administrators, Francine Tattiano and Lauren Cottman, and was granted access into the facility.

During the Case Management-Deficiencies inspection, LPA requested the following document(s):

-LIC 602 for Resident #1

During the Document Review of the LIC 602 (See Document review-LIC 602 dated for April 4, 2023), the resident is unable to leave the facility unassisted. However, Resident R1 eloped from facility without staff knowledge on March 20, 2023 and was found by staff outside of the facility. Current medical assessment for resident states resident is not able to leave facility unassisted.

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 repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview was conducted with the Assistant Administrators and appeal rights were given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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Document Has Been Signed on 04/04/2023 01:44 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: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2023
Section Cited

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87705 Care of Persons with Dementia - (b)
(2)Safety measures to address behaviors such as wandering.

This requirement is not met as evidenced by:
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Licensee/Administrator will submit a Plan of Correction on how future compliance will be met. Furthermore, in-service training was already conducted.
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Based on incident report dated for March 24, 2023, Resident R1 eloped from facility without staff knowledge on March 20, 2023. Staff found resident and resident was escorted back into the community. Current medical assessment for resident states resident is not able to leave facility unassisted.
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Plan of Correction due on April 5, 2023.

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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: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
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