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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:10:23 PM

Unfounded


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
08/22/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240822130836
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: 174DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan WhineryTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not provide written notice of rate increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this Complaint. During the course of this investigation, documents were obtained and reviewed and statements were taken. The following determinations are made: Complainant alleges that facility did not provide written notice of rate increase; Administrator has produced a written document dated 6/28/2024 addressed to the Complaint Subject and the Responsible Person which outlines the rate increases effective 9/1/2024. Based upon the document reviewed, the allegation is determined to be UNFOUNDED, meaning that it is false and, or, without a reasonable basis. The complaint is DISMISSED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 5
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
08/22/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240822130836

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: 174DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan WhineryTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not meet resident's incontinent care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of the investigation site visits were made to the facility, statements were taken and documents reviewed. The following determination are made: Complainant alleges staff are not properly managing R1’s incontinence and the care notes reflect the issue has been brought to the attention of care staff; Care services notes for June thru September, 2024, indicate incontinent checks made by staff were done timely in compliance with care plan; Care services notes indicate R1’s refusal of incontinent checks on several occasions; R1 was more that 30 minutes late to 4 medical appointments in July and September; Care staff state that R1 was checked for hygiene in preparation for the scheduled appointments but may have had an incontinent incident while waiting for delayed transportation. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.
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: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 5
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
08/22/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240822130836

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: 174DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan WhineryTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not follow resident's dietary orders
Facility staff did not provide written incident reports to responsible person
Facility staff did not provide a detailed explanation of the additional services to be provided at the new level of care
Facility staff did not provide an itemization of charges
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of the investigation site visits were made to the facility, statements were taken and documents reviewed. The following determination are made: R1’s Physician’s Assessment dated 1/7/2023 indicates R1 requires a special diet; Entries in care notes for R1 dated 4/4 and 4/11/2024, imply an issue with R1’s served meals and indicate Administrator will remind kitchen staff to follow R1’s special diet; Administrator has stated that R1’s Responsible Person was not provided written copies of Incident Reports; A review of the meeting notes, E-mails and documents show that the explanations of additional services provided R1 were not detailed and the charges for the additional services were not itemized but included in a level of care rating system. Based upon the statements and reviewed documents, 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.
H&S
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: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 21-AS-20240822130836
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: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/08/2024
Section Cited
HSC
1569.6557
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H&S code section 1569.657 For any rate increase due to a change in level of care..licensee shall provide ..resident and resident representative..written…detailed explanation of additional services provided and itemization of charges.
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Facility shall refund additional charges for services but may rebill for the additional services provided the services are outlined in the Admission Agreement and itemized as required by H&S 1569.657. Facility to provide proof of refund and
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****Based on documents and statements, this requirement not met as evidenced by: Facility did not provide R1 detailed explanation of services and charges for changes in level of care. This posed an immediate violation of personal rights.
POC: Facility
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written plan to correctly bill future charges in order to clear the deficiency. Due by POC date
Type B
10/15/2024
Section Cited
CCR
87555(b)(7)
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87555(b)(7) General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. ***Based on documents and statements, this requirement has not been met as evidenced by: Kitchen staff were
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 Administration shall provide a written plan that outlines how facility will ensure that special diets are served to residents when ordered by the physician. Plan due by POC date in order to clear the deficiency.
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reminded by Administration on two occasions to follow diet prescribed by R1’s physician in the assessment of 1/7/2023. This posed a potential risk to R1's health
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240822130836
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: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2024
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident …***Based upon statements, this requirement has not been met as evidenced by: Administrator has stated that written incident reports
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Cleared at time of visit. Facility now provides written incident reports to the residents’ Responsible Persons.
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have not been provided to R1’s Responsible Person. This posed a potential risk to the personal rights and health of Residents in Care.
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5