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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 08/10/2021
Date Signed: 08/10/2021 12:53:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210702143202
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:
08/10/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kayla Young/Assistant DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility has mold
Residents do not receive showers
Residents rooms smell like urine
Facility has an outbreak of a stomach condition
Administrator not on the premises a sufficient number of hours to permit adequate attention to managing facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Kayla Young and toured the facility and grounds. An anonymous complainant has alleged that the facility has mold; that residents' rooms smell of urine and residents are not showered; that residents were sick with stomach issues due to improper handling of food service and that the Administrator is not present sufficient hours to manage the program. This Department has investigated these allegations by obtaining and reviewing documents; interviewing witnesses and staff; and conducting three on site visits to the facility. The following determinations have been made: Multiple inspections did not reveal signs of mold in kitchen and bedrooms; random inspection of Memory Care and Assisted Living bedrooms did not reveal urine odors; In June four residents exhibited stomach flu like symptoms which were reported by facility in compliance with regulations; the source of the cause of the symptoms is unknown; Random review of 40 shower logs between March and July of 2021 indicate residents offered regular showers and that, on occasions, residents refuse a shower;
*****Continued on second page****
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: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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
Control Number 21-AS-20210702143202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 486803806
VISIT DATE: 08/10/2021
NARRATIVE
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During site visits and phone calls to facility, the Administrator has usually been available and on site and was well versed in the facility operations; When Administrator not present the Assistant Administrator has been present. Although the allegations may be true or, are valid, based upon the records reviewed and the statements made, there is not a preponderance of evidence to prove the allegations did or, did not, occur. Therefore, the allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210702143202

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:
08/10/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kayla Young/Assistant DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility has pests
Residents do not receive assistance with incontinence care
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Kayla Young and toured the facility and grounds. An anonymous complainant has alleged that the facility kitchen has rats and maggots and that incontinent residents are not receiving adequate care. This Department has investigated these allegations by obtaining and reviewing documents; interviewing witnesses and staff; and conducting three on site visits to the facility. The following determinations have been made: At the time of inspection, no evidence of rodents/pests was noted but staff, as well as Administration, stated there has been a recent problem with rodents and that on going efforts were being undertaken to alleviate the problem; In June 3 cases of bed bugs and 2 cases of scabies were reported by facility with indication that proper protocols were followed; Resident(R1) stated that R1 has waited up to 2 hours for assistance with incontinence on more than one occasion which results in R1 remaining in soiled diapers while in bed. Based upon the records reviewed and statements taken, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED.
*********Continued on next page********
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: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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
Control Number 21-AS-20210702143202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 486803806
VISIT DATE: 08/10/2021
NARRATIVE
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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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20210702143202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 486803806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2021
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence. …the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. ***Based upon statements taken, this requirement has not been met

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Administration to submit a written plan to CCL by POC date in order to clear the deficiency. Plan shall address how the facility will ensure compliance with the requirements of 87625 going forward.


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as evidenced by: R1 states R1 has waited up to 2 hours for assistance with incontinence on more that one occasion. This posed an immediate risk to the health and welfare of resident.
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Type A
08/13/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) General Food Service Requirements . All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. ***Based upon statements made and documents reviewed, this requirement has not been met as evidenced by:
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Administration to submit the following to CCL by POC date in order to clear the deficiency: proof that the rodent problem has been addressed and that a plan is in place to prevent further occurrences.
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staff and Administration state that there has been an ongoing problem with rodents in the facility kitchen. This poses 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: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5