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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 04/28/2023
Date Signed: 04/28/2023 10:48:08 AM


Document Has Been Signed on 04/28/2023 10:48 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:LAUREN COTTMANFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 167DATE:
04/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Assistant Administrator, Lauren CottmanTIME COMPLETED:
10:00 AM
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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-Incident inspection. LPA was greeted at the door by the Receptionist, Maria Aispuro and was granted access into the facility. Assistant Administrator, Lauren Cottman arrived 30 minutes later.

CCL received an incident report on April 09, 2023 indicating a resident choked on food while eating lunch in the dining room. In addition, CCL received another incident report on April 13, 2023 indicating a resident choked on food during an outing outside of the community. Resident #2 was unavailable for an interview. LPA requested the following documents to be reviewed:

-LIC 602's for Resident #1 and Resident #2
-Additional Supporting Document

No Deficiencies were observed or cited during this Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was given to the Assistant Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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