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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 09/16/2022
Date Signed: 09/21/2022 10:32:18 AM

Document Has Been Signed on 09/21/2022 10:32 AM - 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:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 250CENSUS: 156DATE:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Blaine Lyons - Acting Executive DirectorTIME COMPLETED:
11:00 AM
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
Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned that there are related deficiencies observed during the visit. LPA met with Blaine Lyons - Acting Executive Director. Following item were observed during investigation visits:

Department has learned after alarm records review that facility alarm system on 2/17/2022 show that from 100 % of calls 22 % were answered in a time frame of 10 to 29 min and 9.6 % of calls took 30 min to 1 hr 18 min to be answered. Facility on 2/17/2022 had according to records provided by facility 102 Assisted Living residents'. Acting Executive Director email stated that facility had 1 medication technician and 3 agency care staff. However, facility records show that there were only 3 staff on NOC shift counting medication technician and after 4 AM only one staff on shift. (copy of records on file) Records show that call bell alarms in Assisted Living were not answered in a timely matter to ensure that residents' needs were meet. (see LIC 809-D)

During visit to facility on 8/1/2022 Department reviewed residents' and staff files and learned that 4 out of 4 residents' files have no updated care plan as required by Title 22 Regulations. Residents R1 & R2 have a diagnosis of dementia and care plans dated 7/25 and 3/16/2021 while residents R3 no care plan found – only has a pre-assessment which dates 10/12/2020 & R4 has a care plan in progress that dated 11/9/2018. In addition, resident R4 has a physical assessment (LIC 602) dated 3/31/2021 however; it is not signed. (see LIC 809-D)

Continued 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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 5
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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 09/16/2022
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
26
27
28
29
30
31
32
Regarding staff files review, 3 out of 3 staff don’t have proof of enough training according to Health & Safety Code requirements. Staff S1 was hired on 3/2/2021 with no proof of medication training under this facility, CPR, and/or 1st Aid – only documentation is a Med Tech training from 2016 under facility Nazareth Fairfield. Staff S2 was hired on 11/25/2020 and has proof of a total of 11.5 hours training between 11/26/2020 and 9/29/2021, no proof of CPR and/or 1st Aid certification. Staff S3 has no proof of training or file at facility. (see LIC 809-D) Timecard for staff S3 was submitted to the Department, however; facility has no file and staff is not associated to the facility. According with a week timecard submitted staff S3 worked on 2/13/2022 and 2/17/2022. (see LIC 809-D, Civil Penalties) In addition, none of the staff mentioned above has criminal record statement on file (see LIC 809-D), and staff names from agency that were provided to the Department by Acting Executive Director had only first names. Department wasn’t able to review fingerprint clearance, association, and/or training for these individuals.

Immediate Civil Penalties are being assessed in the amount of $200 due to staff not being associated to the facility.


*****Total Civil Penalties issued today in the amount of $200.00.

Appeal of Rights Given.

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/21/2022 10:32 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 09/01/2022 at 03:38 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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2022
Section Cited
CCR
87355

1
2
3
4
5
6
7
87355 Criminal Record Clearance.This requirement isnt met as evidenced by: Based on records reviewed facility didn't comply w/section above on 1 out of 3 staff fingerprint clearance & staff association before providing
1
2
3
4
5
6
7
Facility to ensure that all facility & agency staff and volunteers are fingerprint cleared and associated to facility before working, residing, and/or voluntering at facility. Facility to provide & submit CCLD with self certification that they understand
8
9
10
11
12
13
14
care to residents which poses an immediate health, safety, & personal rights risk to residents in care.CCLD reviewedtimecards provided by facility & learned that staff S3 isnt associated to facility.Staff S3 worked 2 days between 2/13 & 2/17/22.
8
9
10
11
12
13
14
this regulation and that all staff and volunteer at facility are and will be fingerprint cleared and associated to the facility by 9/17/22. (see Civil Penalty)
Type B
09/29/2022
Section Cited
CCR87412

1
2
3
4
5
6
7
87412 Personnel Records:This requirement is not met as evidenced by: Based on records reviewed & interview facility didn't comply w/section above on 3 out of 3 staff files which poses a potential safety risk to
1
2
3
4
5
6
7
Facility to ensure that all staff documentation required on Title 22 Regulation # 87412 is on file and available for the Department to review when requested. Facility to review staff files and submit to CCLD
8
9
10
11
12
13
14
residents in care. During visit on 8/11/22 LPA requested to review 2 staff files S1, S2, S3 based on timecards provide by facility. Facility staff files for S1 & S2 only contained resume & training. S3 had no file available.
8
9
10
11
12
13
14
Self certification that all staff files have required documentatioin available for the Department to review when requested by POC date of 9/29/22 in order to clear this citation.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/21/2022 10:32 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 09/01/2022 at 04:27 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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
HSC
1569.625

1
2
3
4
5
6
7
§1569.625 Staff training; legislative findings…This requirement isn't met as evidenced by:Based on records review & interviews,licensee didn't comply w/section cited above in 3 out of 3 staff training which poses a potential health,
1
2
3
4
5
6
7
Facility to ensure that all facility & agency staff have initial training required as well as on going training. Facility to provide CCLD with a plan on how facility will ensure that all staff have required training on file as well
8
9
10
11
12
13
14
safety,& personal risk to residents in care.During visit on 8/11 & email follow up, facility wasn't able to provide sufficient initial & on going proof of training for staff S1&S2 and no proof of training for S3.
8
9
10
11
12
13
14
as how it will maintain the on going training and self certification that staff has all training required to be reviewed by the Department by POC date of 9/29/22 in order to clear this citation.
Type B
09/29/2022
Section Cited
HSC1569.618(b)(3)

1
2
3
4
5
6
7
1569.618 (b)(3)Ensure that at least 1 staff member who has cardiopulmonary resuscitation (CPR) training & first aid training is on duty & on the premises at all times.This requirement isn't met as evidenced by: Based on staff file review & interviews
1
2
3
4
5
6
7
Facility to provide CCLD w/ proof of 1st aid for staff S1, S2, S3, and self certification that facility will have at all times/ every shift at least 1 facility staff that carries an active CPR certification by POC date of 9/29/22.
8
9
10
11
12
13
14
3 out of3 staff file had no proof of 1st Aid and on 2/17/22 there were no staff w/ CPR on premises as per 8/11/22 visit and records requested on email which poses a potential health, safety, & personal rights risk to residents in care.
8
9
10
11
12
13
14
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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/21/2022 10:32 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 09/06/2022 at 11:24 AM
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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
CCR
87463(c)

1
2
3
4
5
6
7
87463(c) Reappraisals...once every 12 months...as specified in Section 87467.This requirement is not met as evidenced by: Based on observation,interview, and record review, facility did not comply with the section cited
1
2
3
4
5
6
7
Facility to ensure that reappraisals are conducted at least every 12 months and/or any time there is a change of condition. Facility review residents careplans and provide Department with a self
8
9
10
11
12
13
14
above in 4 out of 4 residents' reappraisals which poses a potential health,safety or personal rights risk to persons in care.Dept learned that residents R1,2,3,4 have no reappraisal or they are over 12 months.(see copies)
8
9
10
11
12
13
14
certification as proof that all careplans/reappraisals have been updated, reviewed & resident and/or responsible party by POC due date of 9/29/2022 in order to clear citation and avoid civil penalties.

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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
Page: 5 of 5