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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804139
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:37:53 PM

Document Has Been Signed on 03/28/2024 05:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 20DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Katrina Brass, Quality Assurance TIME COMPLETED:
03:59 PM
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On 3/28/2024, Licensing Program Analysts (LPA's) Tobola and Mutialu conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Quality Improvement Director, Katrina Brass. The facility currently provides care for 20 clients, some of which were present at the time of visit others of which were on outings. LPA's continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 10/27/2023. Smoke and carbon monoxide detectors were interconnected found throughout the facility. Facility has received a fire safety inspection within the last year but LPA is requesting for documentation from the fire inspection agency on smoke and carbon monoxide alarms. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients were measured between 112.8 & 119.6 degrees F which is within Title 22 Regulations. There is a sufficient supply of linens, hygiene product and paper products available for client use. Items that could pose danger to client if accessible were found to be secured.

Medications are located in a designated medication room and found to be secured. A spot medication count was conducted for clients and LPA's observed several missing inputs on the Centrally Stored Medication Records. LPA has been informed of the facility's plan of contracting with a new pharmacy will no longer be pursuing the contract. The facility is partnering with the current pharmacy and updating protocols on medication intake and orders. LPA's conducted a review for staff files and found all staff to have appropriate training records on file and facility to provide 1st and CPR certification to CCLD for review by correction date 4/2/2024. LPA discussed training requirement expectations and provided regulation information for training topics required for all staff. Technical Advisory issued. LPA's conducted a spot check of client records and found all clients to have updated physician's reports and a needs & service plan or information similar too, on file.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/28/2024
NARRATIVE
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Facility is aware of the requirement to conduct quarterly disaster drill but do not have documentation of completion. The facility is in the process of acquiring a company vehicle for medical transportation services and other outings. Currently, the facility utilizes ride share services to meet the requirements for medical and incidental requirements for client care needs. Upon inspection of client living spaces, LPA's found that the facility does not have an operating auditory signal system. The facility has submitted a request to county services but have not received support at this time.

The facility is currently in the process of assigning a new Administrator but is currently supported by designated responsible parties including Quality Improvement Director, Katrina Brass and Executive Director, Amber Salazar.

Quality Improvement Director, Katrina Brass's Administrator Certification 6064107735 is current through 5/3/2024.

LPA requested the following documents be sent to CCL by COB 4/28/2024:

LIC 308 Designated Facility Responsibility
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Proof of ownership/Control of Property
Fire Alarm and Carbon Monoxide Inspection


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

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/28/2024 05:37 PM - It Cannot Be Edited


Created By: Dominic Tobola On 03/28/2024 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SOLANO HOUSE
FACILITY NUMBER: 486804139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above due to facility signal system found to be inoperable which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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2
3
4
Faciltiy agrees to implement updated auditory alarm system and a proof of corrections form LIC9098 to CCLD by POC date 4/11/2024 indicating corrections and ensuring compliance moving forward.
Type B
Section Cited
CCR
80075(k)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in 4 centrally stored medication records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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4
Faciltiy agrees to conduct an in-service training for all staff on medicaiton management and recording. Signed training to be submitted to CCLD by POC date 4/11/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/28/2024 05:37 PM - It Cannot Be Edited


Created By: Dominic Tobola On 03/28/2024 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SOLANO HOUSE
FACILITY NUMBER: 486804139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and staff interview, the licensee did not comply with the section cited above in due to facility not documenting emergency disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Facility agrees to submit an emergency disaster log to CCLD by POC date 4/11/2024 along with LIC9098 Proof of Corrections form ensuring compliance moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


LIC809 (FAS) - (06/04)
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