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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804139
Report Date: 04/05/2024
Date Signed: 04/05/2024 03:28:48 PM

Substantiated


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
01/26/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240126140539
FACILITY NAME:SOLANO HOUSEFACILITY NUMBER:
486804139
ADMINISTRATOR:HALL, ELIZABETHFACILITY TYPE:
735
ADDRESS:2251,2261,& 2271 S WATNEY WAYTELEPHONE:
(530) 758-2160
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:32CENSUS: 21DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Kacy Goulart, Human Resources DirectorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff do not report incidents involving residents as required
Staff do not ensure that resident's attend medical appointments as necessary
INVESTIGATION FINDINGS:
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On 4/5/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Human Resources Director, Kacy Goulart. LPA’s Tobola, Matialu and Leibert toured the facility, reviewed records and made observations during the course of the investigation.

Complaint alleges staff do not report incidents involving residents as required regarding client (C1) having missed multiple doses of medications. Upon review of facility records and incident reports, LPA found that the facility had reported the incident of client C1 not provided multiple doses of Atropine Sulfate 1% from 1/14/2024 – 1/30/2024. The report was submitted to Community Care Licensing on 2/9/2024, with the incident occurring on 1/30/2024; 3 days past the reporting requirement. In addition, upon review of C1’s medication administration records, it was determined that the facility report was drastically inconsistent with C1’s records, indicating that C1 had not been administered their Atropine Sulfate 1% for nearly one month, from 1/1/2024 – 1/29/2024 due to facility staff placing the medication in the incorrect container.
Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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 3
Control Number 21-AS-20240126140539
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: SOLANO HOUSE
FACILITY NUMBER: 486804139
VISIT DATE: 04/05/2024
NARRATIVE
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Complaint alleges staff do not ensure residents attend medical appointments as necessary. Upon review of facility records and incident reports, LPA found that the facility had reported to Community Care Licensing, that on 1/12/2024, client C1 had not received prescribed medication of Clozapine 100mg from 1/4/2024 - 1/12/2024. The report indicates that the medication order was not delivered due to C1 requiring lab work prior correlating to medication exhaustion. A lab was scheduled for 1/12/2024 but did not correlate with the actual exhausted date. Multiple swing staff failed to communicate prescription supply amount and properly adjust lab dates for proper refill of medication. In addition, upon review of C1's MAR, the report is inconsistent by one day with records showing Clozapine 100mg missed starting on 1/3/2024.

Allegations, staff do not report incidents involving residents as required regarding client and staff do not ensure residents attend medical appointments as necessary are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. 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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240126140539
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: SOLANO HOUSE
FACILITY NUMBER: 486804139
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2024
Section Cited
CCR
80075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidence by:**
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Licensee failed to ensure client C1 had been provided appropriate medical services as needed. Licensee agrees to submit written statement indicating plan of action on how facility will ensure client medical appointments are met. Statement to be submitted by POC date 4/8/2024.
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Based on review of facility incident reports and client medication records, LPA found that the facility did not ensure client C1 was provided appropriate medical lab work based on medication exhaustion of C1's prescribed Cloazpine. This serves as an immediate health & safety risk to clients in care.
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In additon, Licensee to conduct an in-service training for all care staff to review Regulation 80075 Health Related Services. Signed training completed by all staff to be submitted by POC date 4/12/2024.
Type B
04/12/2024
Section Cited
CCR
80061(b)
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Upon the occurrence, during the operation of the facility.. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This was not met as evidence by:**
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Licensee failed to ensure incident was reported in a timely manner. Licensee agrees to conduct in-service training for all staff on Regulation 80061 Reporting Requirements and submit signed training to CCLD by POC date 4/12/2024. In addition, Licensee to submit written statement ensuring that
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Based on a review of faciltiy submitted incident reports, LPA's found that the facility had reported an incident involving a medicaiton error with client C1 missing medication doses, 10 days after incident occurred. This serves as a potential heatlh & safety risk to clients in care.
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the faciltiy will remain in compliance with reporting requirement expectation. Statement to be submitted by POC date 4/12/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
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