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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803806
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:11:00 PM

Document Has Been Signed on 03/06/2025 04:11 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:VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THEFACILITY NUMBER:
486803806
ADMINISTRATOR/
DIRECTOR:		WHINERY,MORGANFACILITY TYPE:
740
ADDRESS:3350 CHERRY HILLS COURTTELEPHONE:
(707) 425-3588
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 250CENSUS: 178DATE:
03/06/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Tony Ibarra, Business Office DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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At approximately 9:40AM, Licensing Program Analysts (LPAs) Hansen and Contreras arrived unannounced to continue a 1 Year Required Visit, and met with Business Office Director (BOD), Tony Ibarra & Ieshaa Ragland, Health and Wellness Director (HWD) as Administrator, Morgan Whinery was not available. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 118 residents in Assisted Living and 60 in Memory Care for a total of 178 residents in care. LPAs were also informed that there were 43 staff members on-site.

On 3/6/2025 at approximately 9:45 am LPAs conducted a sample review of ten residents & ten staff records. LPAs reviewed resident’s files and learned that 10 out of 10 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time and were all found to be well organized, thorough and contained the required documentation as required by Title 22 Regulation.

During staff file review, LPAs observed that 10 of 10 personal files were not readily available for review (see LIC809D). CCL will return to review files at a later date.

LPAs followed up on incident report that was self-submitted to Community Care Licensing (CCL).

Incident Report : CCL received an incident report from the facility on 03/05/2025. Report states that on 03/03/2025, at aprox 2:45pm staff noticed facility alarm door 1 on floor 2 was unarmed when conducting routine door checks, head count conducted finding R1 missing. Facility conducted search, informed law enforcement & family. R1 was found 2 hours later at 4:45pm by law enforcement and returned to facility by law enforcement, after assessment, no injuries noted. Review of R1's physician's report and care plan indicates they are unable to leave unassisted and has a dementia diagnosis (deficiency cited, see LIC809D, Regulation 87705(b)(2).

LPAs are requesting the following documents to update facility file:



Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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Document Has Been Signed on 03/06/2025 04:11 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/06/2025 at 12:41 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)(1)

87412 Personnel Records (g) All personnel records shall be maintained at the facility & shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above not having records available for Licensing to review during visit including updated personnel records which poses a potential health and safety risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee agrees to submit self certification that all resident/staff files are accessible for review and contain all required documents by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 04:11 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/06/2025 at 12:47 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705((b)(2)
87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering..

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above. Resident 1 eloped from facility. R1's Physician Reports state they are unable to leave without assistance and has a diagnosis of dementia. This poses an immediate health and safety risk to residents in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee submitted proof of all staff training conducted on 3/4/2025 & 3/6/2025. Coyp of staff suspension provided. Deficiency cleared during visit, and Plan of Corrections Letter provided.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


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: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 03/06/2025
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Continued from LIC809

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Updated Liability Insurance
Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/21/2025.

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: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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