486803806-1-26-2024-21-AS-JBOS-CZUP75-20240126100321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 01/22/2024
Date Signed: 01/26/2024 10:04:23 AM

Document Has Been Signed on 01/26/2024 10:04 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
SANTA ROSA RO, 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: 148	DATE:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Adminstrator Assisant- Francine Taitano		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 01/22/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator Assistant, Francine Taitano, and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident apartments and common restrooms. There are three activity spaces which had a plethora of supplies for the activities that are scheduled throughout the month. The menu is posted and offers a variety of options for the residents.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster.

Facility has a 2-day perishable and a 7-day non-perishable amount. Hot water temperature was measured in five apartments and measured between 105-120 F. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (5) staff files, which contained most of the required documents. However, three of five staff files reviewed did not include first aid training.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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 01/26/2024 10:04 AM - 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
SANTA ROSA RO, 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: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 3 out of 5 staff records review did not have first aid training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	The facility will provide first aid training and ensure that all first aid training remains up to date for all care staff. The facility will email the LPA proof that the facility is 100% compliant with first aid training for direct care staff.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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