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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:57:35 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
11/18/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20241118124213
FACILITY NAME:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 169DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Morgan Whinery, Administrator TIME COMPLETED:
02:56 PM
ALLEGATION(S):
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Facility staff did not respond to resident's calls for assistance timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of a complaint investigation and delivering findings of the above allegation with Morgan Whinery, Administrator. Facility was toured, observations made, facility records were reviewed and interviews were conducted.
The complaint alleges that Facility staff did not respond to residents' call for assistance timely. LPA conducted an inspection of memory care, reviewed records of call bells for 11/01/2024 through 11/15/2024 and conducted interviews. LPA's review of call bells found that most calls are answered within 3-8 minutes; a reasonable amount of time although call logs indicate that there were multiple calls each day during 11/1/2024 through 11/15/2024 which took from 15 to 31 minutes.

Continued on 9099-C



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 3
Control Number 21-AS-20241118124213
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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 11/19/2024
NARRATIVE
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Continued from 9099....

LPA's inspection of pull cords in bathrooms found one cord which was not responsive on the day of inspection. Review of response system shows that care staff and front desk are notified of service request on their phones. Based on documents reviewed, observations made, and interviews conducted, the allegations that Facility staff did not respond to resident's calls for assistance timely has been Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. (See 9099-D)


Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents. Deficiencies 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: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241118124213
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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General:

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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Licensee to submit a self-certification statement that a plan of action will be written regarding facility staffing and call light system by POC due date of 11/20/24. Plan of action to detail how facility will ensure there is sufficient staff
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This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff were unable to respond to call buttons in a timely manner. Records reviewed indicated that multiple call buttons had response times of 20 minutes or more. This poses an immediate risk to the health and safety of residents in care.
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available to respond to resident care needs in a timely manner. In addition, broken pull cord to be repaired. Plan to be submitted to CCL by POC date of 11/22/2024.
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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: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3