<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804139
Report Date: 10/31/2023
Date Signed: 10/31/2023 04:51:41 PM

Document Has Been Signed on 10/31/2023 04:51 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: 18DATE:
10/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Elizabeth Hall, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/31/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and gathered additional information regarding a client on client (C1 & C2) incident that occurred on 9/16/2023. LPA was greeted by Administrator, Elizabeth Hall. LPA conducted a separate visit on 9/29/2023 to follow up on the incident. LPA toured the facility, interviewed several staff, reviewed records, reviewed facility surveillance footage and made observations. Based on a review of facility surveillance footage, LPA observed the unprovoked assault from client C1 towards client C2. It was found that the incident occurred in the facility dinning area where several other clients were present. C1 was observed to immediately walk into the dining area and proceed towards C2, abruptly leading to C1 striking C2. Behavioral Health Technician (BHT) staff, (S1) was located in the kitchen area with line of sight of client through the kitchen door windows. S1 responded in a timely manner within approximately 12 seconds of the incident initial confrontation.

LPA observed S1 attempting to contact additional BHT staff but due to inconsistencies with the radio walkie system, S1 was unable to successfully contact support. S1 was successfully able to de-escalate the altercation within approximately 11-12 seconds. A second BHT staff (S2) arrived approximately 3 1/2 minutes after the altercation was de-escalated but was not aware the incident occurred. LPA interviewed several staff and based on interviews with staff (S1, S3 & S6) it was consistently found that staff are not properly utilizing the radio system with several staff stating that they've observed other BHT staff either without a radio walkie on their persons or the device being turned off. The facility has implemented a pendant signal system that omits a loud audio signal when activated. During inspection, LPA found that staff S4 did not have either a radio walkie device or pendant signal. S4 additionally admitted that they had removed the pendant signal from their person. LPA and Administrator discussed health & safety risk to clients in care and developed plan of action to remain in compliance moving forward.
Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/31/2023 04:51 PM - It Cannot Be Edited


Created By: Dominic Tobola On 10/31/2023 at 03:21 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: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/10/2023
Section Cited
CCR
80065(a)

1
2
3
4
5
6
7
8065(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidence by:**
1
2
3
4
5
6
7
Administrator is to develop a plan of action to ensure staff are utilizing communication and signal systems appropriately. Written plan of action is to be submitted to CCLD by POC date 11/10/2023. In addition, Administrator is to conduct in-service training on client de-escalation techniques and utiliziation of
8
9
10
11
12
13
14
Based on observation and review of facility video surveillance and interviews with several staff, it was found that the facility radio walkie system is not effective or properly utilized during a client on client incident resulting in client C1 assaulting client C2. This is a potential health & safety risk to clients in care.
8
9
10
11
12
13
14
various commuincation systems. Administrator is to provide scheduled training date to CCLD by POC date 11/10/2023. Once training is completed, Administrator to provide signed copy of certification for all staff by POC date 11/21/2023.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2