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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 03:48:43 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
02/12/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240212092734
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: DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Kacy Goulart, Human Resources DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are not providing resident's medication as prescribed
Staff do not allow resident's to have access to resident's personal files
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, interviewed staff and clients, reviewed records and made observations during the course of the investigation.

Complaint alleges staff are not providing resident's medication as prescribed. Based on interviews with staff (S1) and a review of facility records and incident reports, LPA found that on multiple reported incidents, staff failed to ensure client (C1) had been properly provided multiple medication of Clozapine and Atropine Sulfate 1%. In addition, based on interview with staff (S1) LPA also confirmed that client C1 has missed several doses of their prescribed medications due to medication room staff errors.

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 5
Control Number 21-AS-20240212092734
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 allow residents and resident responsible parties to have access to personal files. Upon interview with staff (S2) LPA found that client’s (C1) conservator (I1) had requested for C1’s medication administration records from the facility and was refused. In addition, LPA interviewed C1's conservator (I1) who also confirmed that they were denied access to C1's records.

Allegation, staff are not providing resident's medication as prescribed and staff do not allow residents and resident responsible parties to have access to personal files. 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 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
02/12/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240212092734

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: DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Kacy Goulart, Human Resources DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff do not ensure resident's are provided nutritional meals
Staff do not meet resident's dietary needs
INVESTIGATION FINDINGS:
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**This is an amended version of the LIC9099-A indicating correct allegation list**

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, interviewed staff and clients, reviewed records and made observations during the course of the investigation.
Complaint alleges, staff do not ensure resident's are provided nutritional meals. Upon interviews with staff (S2 & S3) and clients (C1,C2,C3, C4 & C5), LPA was provided inconsistent information on food options provided to clients. Upon inspection of facility kitchen and food supply, LPA’s found that the facility does have an adequate supply of both perishable and non-perishable foods that appear to be nutritious in value.

Continued onto LIC9099-C
Unsubstantiated
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: 3 of 5
Control Number 21-AS-20240212092734
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 meet resident's (C1’s) dietary needs. Upon interviews with staff (S1 & S2), LPA was informed by that C1 was requested by their physician to maintain a general healthy food diet. LPA was informed that there were no specific dietary restrictions but that staff encouraged C1 to follow orders. Staff (S1 & S2) both stated that C1 was able to leave the facility freely as well as order their own food by mobile delivery services. Based on statements, C1 was often purchasing unhealthy food items independently.

A finding that the complaint allegations, staff do not ensure resident's are provided nutritional meals and staff do not meet resident's (C1’s) dietary needs are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency cited.
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: 4 of 5
Control Number 21-AS-20240212092734
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)
Request Denied
Type A
04/08/2024
Section Cited
CCR
80075(b)(5)(B)
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Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. This was not met as evidence by:** Based on a review of facility reported incidents and client (C1) medication records, LPA's found that the facility failed to ensure C1 was properly
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Licensee failed to ensure client(s) were provided medication prescribed. Licensee agrees to conduct a full medication audit from an outside or partnering pharmacy with documentation from the pharamacy of completion. Signed documentation to be submitted to CCLD by POC date 4/12/2024.
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administered prescribed Clozapine and Atropine Sulfate as per physician's order. This serves as an immediate health & safety risk to clients in care. A civil penalty of $250 issued for repeat violation within a 12-month period.
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In addittion, Licensee agrees to submit LIC9098 Proof of Corrections form incidating the facility understands regulation by 4/8/2024.
Type B
04/12/2024
Section Cited
CCR
80070(e)
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(e) A client's records shall be open to inspection by the client's authorized representative(s), if any. This was not met as evidence by:** Based on interviews with staff and outside parties,
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Licensee failed to ensure client's representative/conservator was provided access to C1's records. Licensee agrees to submit written statement on how they will remain in compliance with regulation and plan of action on staff and outside conservatorship communication.
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LPA's found that client (C1's) conservator was denied access to C1's medical records. This serves as a potential personal rights risk to clients in care.
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Statement to be submitted to CCLD 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)
Page: 5 of 5