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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:55:48 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
06/14/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230614123412
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: 168DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Francine TatianoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Licensee does not ensure facility is adequately staffed to meet resident’s needs.
Licensee does not ensure residents are provided a clean mattress.
Staff do not assist residents with bathing as needed.
Staff do not ensure medication is administered to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrives unannounced and meets with Assistant ED to deliver findings. Investigative determinations follow: Residents' mattress, which was damaged as a result of overflowing toilet, was professionally cleaned by facility but not to satisfaction of resdients; facility subsequently reimbursed for a new mattress; Shower logs indicate R1 consistently refused to shower and that R2 was showered by staff in substantial compliance with R2's care plan; LPA received photographs which allegedly depict R1's medication loose on the floor of R1's room; R1's physician has indicated that R1 is able to administer and store R1's medications; Although there has been incidents where staff did not respond to calls for assistance in a timely manner and allegations that staff have been observed to be not fully alert while on duty, no direct evidence was found to prove these issues are the result of inadequate staffing. Although the allegations may be true, or valid, based upon the statements taken, documents reviewed and site visits made to the facility, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, the allegations are UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
06/14/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230614123412

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: 168DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Francine TatianoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not respond to resident calls for assistance in a timely manner
License does not insure that facility is in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrives unannounced and meets with Assistant ED to deliver findings. Investigative determinations follow: Call response times for Complaint Subjects’ room for the period of May 11, 2023 thru May 13, 2023 averaged 39 minutes and 51 seconds; 8 were over 20 minutes, 2 calls for May 12 took 1 hour, 9 minutes and 3 hours, 35 minutes for staff response; photographs taken at the facility in February 2023 show furniture blocking outdoor passageway; photographs taken in December 2022 show extension and assorted electrical cords across Residents’ bed and pillows and loose medication on floor. Based upon statements, reviewed documents, observations and photographs, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. $250.00 civil penalty issued for repeat violation and $500.00 immediate civil penalty issued for Zero Tolerance violation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230614123412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. ***Based upon statements and photographs, this requirement not met as evidenced by: Extension and assorted electrical cords were noted across the bed and pillows of
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Administration to submit written plan, which will include additional staff training, which addresses how facility will avoid the reoccurrence of safety issues effecting residents in care. Plan to be submitted to CCL by POC date in order to clear the deficiency.

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R1 and R2 in December of 2022; loose medication belonging to R1 was noted on the floor and furniture of R1’s room in December 2022. This posed and immediate risk to health and safety of residents. Civil penalty for $250.00 Issued for repeat violation within 12 months.
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Type A
08/29/2023
Section Cited
CCR
87303(i)(1)(2)
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Maintenance and Operation. Facilities licensed for 16 or more…shall have a signal system which meets specified requirements. ***Based on statements and written log reports, this requirement not met as evidenced by: Of 14 calls for assistance to room of R1 and R2 for 3


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Administration to submit a written plan that addresses how facility will ensure that calls for assistance are answered timely going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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days in May 2023, 8 were over 20 minutes and 1 over an hour and 1 over 3 hours. This posed an immediate risk to health and safety of residents.


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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20230614123412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
87307(d)(6)
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Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. *** Based upon statements and photographs, this requirement not met as evidenced by: In February of 2023 and other occasions, furniture was
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Administration will provide additional training to staff regarding the importance of complying with the requirements of 87307. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.

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observed to be blocking outdoor passageways in the Memory Care Unit of the facility. This posed an immediate risk to safety of residents. Immediate Civil Penalty issued in amount of $500.00 for Zero Tolerance violation.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4