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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804139
Report Date: 12/19/2023
Date Signed: 12/19/2023 06:28:48 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
12/13/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20231213151231
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: 19DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Elizabeth Hall, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff did not provide adequate food service
Staff mismanaged resident medication
INVESTIGATION FINDINGS:
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On 12/19/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation. LPA toured the facility, interviewed staff, reviewed client and medication records and made observations.

Complaint alleges staff did not provide adequate food service. Based on a tour of the facility kitchen, LPA observed a carton of heavy whipping cream with best by date 11/29/2023; 20 days past the best by date. Food safety procedures are posted in kitchen area and incorporated in facility operation. Guidelines on the food storage protocol indicate "dairy products will still be of good quality for 10-14 days past their "use by" date..". Photos of dairy product and food storage protocol taken.

Complaint alleges facility emergency call system is in disrepair. Based on LPA observations the facility signal system hub and mobile device connected to emergency call buttons in client bedrooms were found to be unplugged and not operating at time of inspection. In addition, staff indicated that the signal buttons from client bedrooms are currently not working. Continued onto LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 4
Control Number 21-AS-20231213151231
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
VISIT DATE: 12/19/2023
NARRATIVE
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Allegation, staff did not provide adequate food service and facility emergency call system is in disrepair are 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.

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.

LPA will require additional time to investigate remaining allegation.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20231213151231
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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2023
Section Cited
CCR
80076(a)(1)
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Food Services 80076(a)(1). All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidence by:
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Administrator agrees to conduct an audit of perishable food supply and clear any items that are spoiled or expired past shelf life code accordng to the facility's food storage protocol. Self-certification LIC9099 to be submitted to CCLD by POC date 12/27/2023 indicating audit has been completed.
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Based on a tour of the facility, review of facility documents, photo evidence and LPA observation it was found that a carton of heavy whipping cream (dairy product) was 20 days past best/use by date of 11/29/2023. Facility food storage protocol posted in kitchen indicates dairy items will be of good quality for 10-14 days after use by date. This serves as a potential health and safety risk to clients in care.
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Administrator will contact the maintenance manager and submit a written plan to either repair or replace the current intercom. Admin to include in plan indicating how facility will remain in compliance and confirming signal systems are on.
Type B
12/27/2023
Section Cited
CCR
85088(f)(1)
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85088(f)(1) - Fixtures, Furniture, Equipment and Supplies. Facilities shall meet the following signal system requirements:..and all facilities having separate buildings... shall be a signal system... This requirement was not met as evidenced by:
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and operating. Written plan to be submitted to CCLD by POC date 12/27/2023.
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Based on facility tour, photo evidence, staff statement and LPA observation, the facility signal system "Retekess" was found to be unplugged and not operating at time of visit. This serves as a potential health and safety risk to 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: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4