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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804139
Report Date: 08/25/2023
Date Signed: 08/25/2023 01:07:32 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
07/10/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230710111714
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: 12DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Elizabeth Hall, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff did not ensure resident was administered medication.
INVESTIGATION FINDINGS:
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On 8/25/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Elizabeth Hall. LPA toured, interviewed clients, reviewed facility files, medication records and made observations.

Complaint alleges staff did not ensure resident was administered medication. Based on a review of facility records LPA found that on several dates May 6, May 21 and June 28, 2023 the facility had improperly administered medications by administering at the wrong dosage or at the incorrect time based on prescription.

Allegation, staff did not ensure resident was administered medication, is 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. Appeal Rights Given
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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
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
07/10/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230710111714

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: 12DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Elizabeth Hall, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
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7
8
9
Staff does not provide residents with a comfortable and safe environment
INVESTIGATION FINDINGS:
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13
On 8/25/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Elizabeth Hall. LPA interviewed clients, reviewed facility files, medication records and made observations.

Complaint alleges staff does not provide residents with a comfortable and safe environment regarding staff (S1). Upon review of staff training (S1, S2, S3 & S4), LPA found that all staff have completed appropriate training on personal rights and client abuse reporting. Based on interviews with clients (C1, C2, C3 & C4), information provided was inconsistent towards the allegation. Due to a lack of corroborating evidence, the allegation is found to be unsubstantiated.

Allegation, staff does not provide residents with a comfortable and safe environment are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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 3
Control Number 21-AS-20230710111714
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: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/25/2023
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. ***Based on statements and documents, this requirement not met as evidenced by: On May 21;May06; and June 28,2023, clients were dosed incorrectly and were
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Cleared at time of visit. Staff have been provided additional medication. Proof of Corrections Form LIC9098 to be signed and submitted to CCLD
by POC date 8/28/2023.
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given the wrong dose amount or administered at the wrong time. This posed an immediate risk to the health of the clients 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3