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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804218
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:10:17 PM

Document Has Been Signed on 08/01/2024 02:10 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 LIFE HOUSE ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
486804218
ADMINISTRATOR/
DIRECTOR:
FELIX, MARYFACILITY TYPE:
740
ADDRESS:575 S JEFFERSON STTELEPHONE:
(707) 678-1651
CITY:DIXONSTATE: CAZIP CODE:
95620
CAPACITY: 38CENSUS: 25DATE:
08/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Mary Felix, ADministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a pre-licensing inspection of the facility to be licensed as Solano Life House Assisted Living and Memory Care. LPA met with Administrator Mary Felix, who will continue in this role under the new license. Licensees Amy Buccat and Charles Bell were also in attendance. There were 25 residents at the time of inspection.

LPA toured the facility and found it to be clean and in good repair. The bedrooms were furnished within regulation, including a bed, chair, night stand, lighting and storage. Each bedroom has an attached bathroom including grab bars and non-skid mats, soap and paper towels. Water temperature in the facility measured between 116-119.6 degrees F, which is within regulation. The facility includes a large great room where dining, activities and socialization occur. There is a large fireplace in the corner of the room, which is screened. There is a medication room which is locked and secured at all times. There is an executive office, a laundry room and kitchen. The kitchen was clean and sanitary and well-organized. The refrigerator and freezer were clean and proper temperature. Food was appropriately stored and dated. There was an ample supply of perishable and non-perishable food, as well as emergency supplies and water. The grounds of the facility were fenced and there was a shaded area available for residents use. Five fire extinguishers were last inspected on 04/30/2024 and fully charged. Fire department inspected facility on 03/20/2024 and found no violations. An emergency disaster plan was submitted, and the applicant has identified at least two evacuation locations.

Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 LIFE HOUSE ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 486804218
VISIT DATE: 08/01/2024
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Continued from 809

LPA observed the following postings: personal rights, emergency disaster drills, activity calendar and menu and the "See Something, Say Something" and "Let Us Know" poster.

LPA did a review of personnel and resident files and found them to be complete.

LPA conducted a COMP 3 with applicants; some of the following items were discussed: reporting requirements, maintenance and operation, personal accommodations and criminal background clearance.

LPA found no concerns. There were no deficiencies found at the time of inspection. No citations.


This pre-licensing is complete. LPA will submit the pre-licensing report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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