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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804139
Report Date: 06/20/2024
Date Signed: 06/20/2024 06:35:21 PM

Document Has Been Signed on 06/20/2024 06:35 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/
DIRECTOR:		HALL, ELIZABETHFACILITY TYPE:
735
ADDRESS:2251,2261,& 2271 S WATNEY WAYTELEPHONE:
(530) 758-2160
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 32CENSUS: 21DATE:
06/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:01 PM
MET WITH:Wendi Counta, Acting AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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On 6/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on an incident report submitted by the facility and received by Community Care Licensing Regional Office on 6/20/2024. Incident report indicates that on 6/9/2024, client (C1) had eloped from the facility and returning multiple days after on 6/13/2024. Facility staff properly contacted and filed missing persons report to the local police department. Although facility submitted incident report to Community Care Licensing, the report was not submitted within 7-days of occurrence.

Citation has been issued under Title 22 regulation, 80061(b) - Reporting Requirements.

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. Appeal of rights provided.

A Civil Penalty for a total of $250 has been issued for a repeat violation within a 12-month period.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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Document Has Been Signed on 06/20/2024 06:35 PM - It Cannot Be Edited


Created By: Dominic Tobola On 06/20/2024 at 06:17 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: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2024
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements: ...In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.. This was not met as evidence by:**
Faciltiy failed to notify and submit written
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Administrator to submit LIC9098 indicating that they have reviewed and understand Regulation 80061, Reporting Requirements. LIC9098 to be submitted to CCLD by 6/27/2024. In addition, Administrator to provide plan of action on how facility will remain in
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incident report to CCLD based on reporting requirements timeframes. This serves as a potential health & safetey risk to clients.
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compliance with reporting requirements. Written statement to be submitted by POC date 6/27/2024.

A Civil Penalty for a total of $250 has been issued for a repeat violation within a 12-month period.

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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