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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:27:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:HALL, JAMESFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 140DATE:
09/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Noma Malik, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Noma Malik. Later during visit, Administrator, Noma Malik had to leave facility and Kayla Young, Assistant Director, was given consent from Administrator to sign report. The purpose of these case management inspections were to follow up multiple self reported incidents reports submitted to Community Care Licensing (CCL).

First incident, 8/20/21, facility reported R1's death. During visit LPA Lopez requested documents and took statements from staff and Administrator.

Second incident, SOC341 was reported to CCL on 7/30/21, R2's money missing. During visit LPA Lopez gathered records, took statements from staff and Administrator. Facility has been in contact with ombudsman, police and responsible party.

Third incident, 8/23/21, R3 had a fall with injury. During visit LPA Lopez gathered records, and took statements from staff and Administrator.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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