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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 02/21/2025
Date Signed: 02/21/2025 11:32:02 AM

Unsubstantiated


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
12/17/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241217141015
FACILITY NAME:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:WHINERY,MORGANFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 174DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tony Ibarra/Business Office DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not prevent a physical altercation between residents
Licensee does not have sufficient staffing to meet the needs of residents in care

INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Resident (R1) was involved in physical altercation with another resident on 10/28/2024. Staff (S1) observed R1 pushing another resident's wheelchair which resulted in yelling and a physical altercation between R1 and the other resident. According to the Incident Report dated 11/14/2024, staff intervened between the residents and separated the residents. No injuries were noted. Staffing levels were noted at the time of R1's elopements from the facility on 10/13 and 11/12 and during the altercation noted above. Twenty-three residents were present in the unit during the incidents. On 10/13 and 11/12, 5 staff were present and on 10/28, 6 staff were present. Although the allegations may be true, based upon the statements and documents reviewed, there is not a preponderance of evidence to prove the allegations are, or are not, valid. Therefore, the allegations are UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
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 5
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
12/17/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241217141015

FACILITY NAME:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR:WHINERY,MORGANFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:250CENSUS: 174DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tony Ibarra/Business Office DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not provide resident's authorized person adequate notice of rate increase
Resident eloped from the facility due to lack of care / neglect from staff
Staff did not follow reporting requirements

INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. According to facility’s documents rate increases for change in level of care for R1 were effective 10/04/2024 and 10/21/24 and the required written notice to R1’s Representative were given on 10/09/2024 and 10/25/2024, respectively. H&S Code section 1569.657(a) requires written notice within 2 business days; R1 eloped from the Memory Care Unit on 10/13/2024 at approximately 7:30 pm and remained away therefrom until returned by Law Enforcement at approximately 9pm; According to Facility’s Incident Report staff on duty were unaware that R1 was missing until returned by Law Enforcement; R1’s Representative states that the Representative did not receive copies of reports of incidents occurring on 10/13/24 and 11/12/24 until 01/22/2025; The Incident Reports of 10/13 and 11/12 are blank in the section that would indicate notice given to the Representative and neither are dated. Based upon statements and documents, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. Continued on next page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20241217141015
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: 02/21/2025
NARRATIVE
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. The following deficiencies were observed (see LIC 9099D) 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. Civil Penalty in the amount of $500 issued for Zero Tolerance of Absence of Supervision.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20241217141015
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: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
CCR
87411(a)
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. Facility personnel shall be sufficient in numbers, and competent to provide the services necessary to meet resident needs. *** Based upon interviews and records reviewed, this requirement not met as evidenced by: On 10/13/2024 R1 left facility without staff’s knowledge and
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 Facility to submit written plan to ensure the prevention of elopements from facility going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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 remained away therefrom between 7:30pm and 9pm when R1 was returned by Law Enforcement. R1’s has dementia cannot leave facility unassisted. This posed an immediate risk to the safety of R1.

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***Civil Penalty issued in the amount of $500.00 for Zero Tolerance of Absence of Supervision.****
Type B
02/28/2025
Section Cited
HSC
1569.657(a)
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CA H&S 1569.657(a)For any rate increase (for) change in level of care …the Licensee shall provide…written notice..within two business days. *** Based on statements and documents, this requirement not met as evidenced by: R1’s Representative was provided written
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Administration will review 1569.657 and submit written plan that outlines how facility will comply going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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notice of increase effective 10/04/24 on 10/09/24 and effective 10/21/24 on 10/25/24. This posed a potential risk to the personal rights of the Resident.
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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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20241217141015
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: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87211(a)
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87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of…Any incident which threatens the welfare, safety or health of any resident….***Based on statements and
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Administration will submit a written plan outlining how facility will comply with 87211 going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.


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documents reviewed, this requirement has not been met as evidenced by: Responsible Person for R1 was not provided copies of Reports for R1’s elopements from facility on 10/13 and 11/12 until 01/22/2025. This posed a potential risk to the personal rights and safety of R1.
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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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5