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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804139
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:36:52 PM

Document Has Been Signed on 08/22/2023 12:36 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: 12DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jessica StillmanTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst Leibert arrived unannounced and met with Jessica Stillman to discuss three incidents involving medication errors. The errors occurred on May 21, 2023 and May 06, and June 28, 2023. The errors involved wrong dose amounts and wrong time of administration. None of the errors resulted in any health complications for the clients. Subsequent to the errors discovery, Administration provided additional training to the staff who administer medications to the clients.

The following deficiencies were observed (see LIC 809D) 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.

Report left

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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Document Has Been Signed on 08/22/2023 12:36 PM - It Cannot Be Edited


Created By: David Leibert On 08/22/2023 at 12:06 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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2023
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 training by Administration.
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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.
SUPERVISOR'S NAME:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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