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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:36:20 PM


Document Has Been Signed on 08/08/2024 12:36 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: 142DATE:
08/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan WhineryTIME COMPLETED:
01:30 PM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on 2 incident reports involving medication errors. LPA met with the Administrator and discussed the incidents. On July 22, 2024, two residents, R1 and R2, missed their scheduled pm injections and on July 23, 2024, R1 missed a AM injection. The error was discovered on 7/23/24 and it was determined that the nurse scheduled to work the shift did not come to work and med techs on duty did not know that management was not made aware of the issue when it occurred. As a Result, all 17 staff who dispense medications were given additional training by Omnicare Pharmacy on August 01, 2024. R1 and R2 were given additional wellness checks and suffered no apparent difficulties. All required notifications were made.

The following deficiencies were observed (see LIC 809D) 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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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 08/08/2024 12:36 PM - 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
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: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2024
Section Cited
CCR
87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. ***Based on documents and statements, this requirement has not been met as evidenced by: On July 23 and July 24
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Cleared at time of visit. 17 staff who provide medication administration have been retrained on administration of medications.
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R1 and R2 were not administered injections ordered by the physician. this posed an immediate risk to the health of the 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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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