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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 07/10/2025
Date Signed: 07/10/2025 10:54:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/14/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250414112833
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: 161DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Morgan WhineryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are mismanaging residents' medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator, Morgan Whinery.

Staff are mismanaging residents' medications - Complainant speaks of 2 medication errors one for (R1) & one for (R2). CCL completed complaint investigation 21-AS-20241018104643 on 10/29/2024 finding Medication Error substantiated regarding insulin for (R2) citing 87465(a)(4). On 6/13/2025 CCL received “medication error documentation” made on 4/6/2025 by HWD when resident (R1) returned from the hospital (4/2/25) the medication list was not updated, and resident (R1) was receiving 2 anti-seizure medications at the same time instead of discontinuing one of them. Based on interviews conducted and record review, the allegation Staff are mismanaging residents’ medications is Substantiated.

Continued LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 8
Control Number 21-AS-20250414112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 07/10/2025
NARRATIVE
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Continued from LIC9099...

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided.

Exit interview conducted with Administrator, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/14/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250414112833

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: 161DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Morgan WhineryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff does not provide adequate supervision resulting in residents wandering away from the facility.
Staff are not properly trained to meet residents' care needs.
Staff does not ensure facility is free of bed bugs.
Staff do not follow proper infectious disease protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator, Morgan Whinery.

Staff does not provide adequate supervision resulting in residents wandering away from the facility-- Complainant alleges there have been two separate resident elopements in the past three months and the facility failed to implement preventative measures or adjust protocols to prevent recurrence. On 3/6/2025 LPA conducted continuation of annual inspection and cited 87705(b)(2) facility for incident report CCL received on 03/05/2025. Indicating on 03/03/2025, at approx. 2:45pm staff noticed facility alarm door 1 on floor 2 was unarmed when conducting routine door checks, head count conducted finding resident (R1) missing.

Continued LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 21-AS-20250414112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 07/10/2025
NARRATIVE
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Continued from LIC9099A...

LPAs did not find any other incident reports of elopements, Health and Wellness Director (HWD) informed there has only been the one in 2025 that fits the parameters of this situation of a resident leaving the facility and staff not visually seeing them. Administrator informed and training records obtain corroborate from 3/4/25 to 4/15/25 facility began 2X per week (sometimes more) preventative elopement training drills totaling 17 for this time frame. Complainant also alleges “the facility is dangerously understaffed”. Interview with Administrator and records reviewed revealed for April 2025 facility is fully staffed with 3 LVN’s, approximately 20 Med Techs (AL: 3 on AM, 3 on PM, & 2 on NOC) MC 1st floor (1 AM, 1PM, & 1 NOC) MC 2nd floor (different MT’s ,1AM, 1PM, & 1 NOC) 70 Caregivers-AL (AM-7, PM-7, NOC-4) MC 1st floor(AM-4, PM-4, NOC-2) MC 2nd floor(AM-4, PM-4, NOC-3). Resident assistant level for April 2025 -2 person assists - 7 in MC (split in the 2 units) & 10 in AL (also split between 3 levels), 50 (1) person assist & 94 no assist. Based on information provided, alarms were turned off, and not necessarily due to lack of staffing. There was no information obtained that supported a violation had occurred. Therefore, the allegation Staff does not provide adequate supervision resulting in residents wandering away from the facility is Unsubstantiated.

Staff are not properly trained to meet residents' care needs – Complainant alleges unlicensed staff are routinely instructed by management to insert urinary catheters and perform catheter. LPA attempted contact with complainant 3 times but was unable to get response for follow up questions. Interview with HWD revealed there are 6 residents receiving catheter care and Home Health staff does all of the care regarding this. Administrator indicated Facility protocols indicate catheters are allowed and the care partner can ONLY empty the catheter and HWD will arrange with third party (HH, hospice or MD office) to change the catheter and if the catheter is pulled staff are to send them out to hospital to get it reinserted, unless the third party made arrangement to come right away to reinsert at the community. The staff need to be trained how to empty the catheter and what to look for reporting. Each resident with catheter must have individualized in-service and care planned according. Supplies for any catheter needs, are NOT paid by the community. There was no information obtained that supported a violation had occurred. Therefore, the allegation Staff are not properly trained to meet residents’ care needs is Unsubstantiated.

Continued LIC9099C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 21-AS-20250414112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 07/10/2025
NARRATIVE
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Continued from LIC9099C...

Staff does not ensure facility is free of bed bugs- Complainant alleges when resident (R3) was admitted to facility they had a bedbug infestation that was withheld from staff. Documents reviewed reveal R3 care notes from move in to 4/14/25 do not indicate any Bedbugs, Medical/mediation assessment of 4/10/2025 also does not indicate Bedbugs, and R3’s initial assessment of 4/11/25 indicates Resident’s skin is clear and intact & resident utilizes base services laundry, one load of linen & one load of clothing. 4/15/2025 Interview with Administrator indicated they do not have any bedbugs in the facility that they are aware of. 5/29/25 interview with staff HWD also indicated to the best of their knowledge there is no bedbugs in the facility, “We would definitely be getting calls from residents and observing bites and rashes of unknown origin”., therefore the allegation Staff does not ensure facility is free of bed bugs is UNSUBSTANTIATED.

Staff do not follow proper infectious disease protocols - Complainant alleges several residents tested positive for MRSA, yet there was no PPE provided outside their rooms. Interview with Administrator in April 2025 revealed there are no contagious diseases currently. Facility had one AL resident (R1) on precaution that came back from the Hospital approximately 2 weeks ago with it but is no longer a concern. This was only contact precautions and R1 was here only 1 day before returning to the hospital. Full isolation containers were outside of room with (gloves/gowns/goggles). Interview with HWD corroborates Administrator indicating R1 was detected with MRSA in urine and went out to hospital next day. Facility implemented containers of PPE outside of this room. Based on information provided there was only 1 resident with contact precautions of MRSA and PPE was implemented outside of their room, although they were only in the facility 1 day prior to being sent out. There was no information obtained that supported a violation occurred. Therefore, the allegation Staff do not follow proper infectious disease protocols is UNSUBSTANTIATED.

A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/14/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250414112833

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: 161DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Morgan WhineryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not properly assessing residents prior to admissions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Administrator, Morgan Whinery.

Staff are not properly assessing residents prior to admissions- Complainant alleges there is "Improper Resident Placement in Memory Care which includes residents without dementia diagnoses who have schizophrenia diagnosis. Interview with HWD there are 2 residents admitted with Schizophrenia diagnosis, now living in MC and have not had any issues. None of the abuse/ aggressive allegations have involved either of these residents. Residents are not exhibiting behavior that would prohibit them from living in an RCFE. There is nothing in regulations that prohibits somebody with a mental health diagnosis from being admitted.

Continued LIC9099C...


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 21-AS-20250414112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE
FACILITY NUMBER: 486803806
VISIT DATE: 07/10/2025
NARRATIVE
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Continued from LIC9099A...

Therefore, the allegation Staff are not properly assessing residents prior to admissions is Unfounded.
This agency has investigated the above allegation alleging Staff are not properly assessing residents prior to admissions. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 21-AS-20250414112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.
This requirement not met by licensee as evidenced by: Based on interviews and facility's incident report of medication error of not discontinuing one of R1’s,
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Licensee submitted certification of medication training along with additional 8 hrs of medication training.

Citation cleared at time of visit.
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 2 anti-seizure medications as indicated by Dr., which poses an immediate health, safety or personal rights risk to persons in care.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8