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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 06/06/2023
Date Signed: 06/06/2023 12:53:15 PM


Document Has Been Signed on 06/06/2023 12:53 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:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 151DATE:
06/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Agustin Samaniego
Assistant Administrators, Francine Tatiano and Lauren Cottman.		TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Village at Rancho Solano Assisted Living, The for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Administrator, Agustin Samaniego, and was granted access into the facility. Also participating in the Case Management-Incident Inspection was Assistant Administrators, Francine Tatiano and Lauren Cottman.

CCL received an Death Report on May 19, 2023 indicating a resident was not on Hospice and passed away. However, the hospital was in the process of transitioning the resident on Hospice when the resident passed. Care Plan was updated on April 28, 2023 before the resident passed away. All appropriate parties were notified including CCL. Resident's private room is currently empty and all the belongings have since been retrieved by the Responsible Party.

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 Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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