486803806-10-26-2023-21-AS-DTOA-CWYNM8-20231026103444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 10/26/2023
Date Signed: 10/26/2023 10:34:46 AM

Document Has Been Signed on 10/26/2023 10:34 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, THE		FACILITY NUMBER:	486803806
ADMINISTRATOR:	AGUSTIN SAMANIEGO		FACILITY TYPE:	740
ADDRESS:	3350 CHERRY HILLS COURT		TELEPHONE:	(707) 425-3588
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	250	CENSUS: 106	DATE:	10/26/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Augustin Samaniego, Administrator		TIME COMPLETED:	10:00 AM

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On 10/26/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced case management visit and met with Administrator, Agustin Samaniego. The purpose of the visit is to follow up on a self-reported SOC341 Report of Suspected Abuse involving a resident (R1) observed by staff to be engaging in inappropriate sexual behavior with two other residents (R2 & R3). LPA spoke with Administrator and Memory Care Director to review interventions to prevent further behaviors of this nature. The residents involved in the incident are admitted to the memory care unit and have demonstrated similar behaviors in the past. All resident families and responsible parties have been notified of the incident and were previously aware of the behaviors of the three residents involved.

The facility has implemented additional supervision for residents R1, R2 & R3 and have also increased the amount and duration of activities to keep R1 engaged in the community. The facility has properly submitted the appropriate reporting documents to Licensing in a timely manner.

Lastly, LPA followed up on a recent death report submitted for resident R4 who LPA confirmed was not receiving hospice services. Fairfield Police Department have conducted an investigation with pending completion of their report. The facility will provide LPA a copy once received. LPA was also provided with the investigating officer's contact and case number in case of further information.

No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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