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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 08/28/2025
Date Signed: 08/28/2025 02:34:18 PM

Unsubstantiated


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
07/10/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250710112626
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: 165DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Morgan Whinery, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not timely respond to the residents alerts
Staff are leaving the residents unattended
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Morgan Whinery.

Staff do not timely respond to the residents’ alerts – Complainant alleges that response times to resident call buttons are frequently delayed. During this investigation LPAs made observations, reviewed records, and conducted interviews. Review of Family Council Minutes dated 7/9/2025 show concerns with wait times following call button activation with a resident alleged to have waited 47 minutes before alert was answered. Interview with five (5) of twelve (12) residents indicated they have heard of another resident waiting up to 45 minutes for help after call button activation but have not experienced the delay themselves. Of these five (5) residents, four (4) indicated it was the same individual mentioned in 7/9/2025 Family Council. One (1) of twelve (12) residents stated they waited up to fifteen (15) minutes after activating alert button.

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

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
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 2
Control Number 21-AS-20250710112626
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: 08/28/2025
NARRATIVE
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Continued from LIC9099...

Review of Resident Council Meeting Minutes indicated that residents attending had no comments regarding Resident Care/Nursing. Seven (7) of twelve (12) residents interviewed stated they have not experienced or heard of other residents waiting longer then ten (10) minutes for help after call button activation. Over the course of the investigation, LPA observed receptionist calling out alerts for both MC and AL they received to caregiver over radio. Call outs consisted of specific location of the alert or specific resident calling if alert came from a resident specific pendant. Callouts were repeated until a caregiver responded. LPA did not witness any call out go unanswered for longer than ten minutes. LPA opened an alarmed door to the outside and a caregiver came within five minutes to check.

Staff are leaving the residents unattended – Complainant alleges residents have been left unattended during clear moments of need and that staff are often unable to meet the needs of the residents due to understaffing. During this investigation LPAs made observations, reviewed records, and conducted interviews. Four (4) of twelve (12) residents interviewed stated they felt or heard concerns from other residents that facility was understaffed on certain days. Four (4) of five (5) staff interviewed felt they were overworked and in need of more staff. Eight (8) of twelve (12) residents interviewed stated they did not have any concerns with understaffing and staff are attentive to their needs. Review of staff Memory Care (MC) and Assisted Living (AL) staff schedules for July and August indicated sufficient staffing for resident care. LPA observed 12 residents in MC first floor main room with six (6) staff rotating care and two (2) dedicated staff leading activities. LPA observed ten (10) residents in MC second floor main room and five (5) caregivers. Administrator stated there are currently no residents on 1-on-1 care plans and facility has started to back hire staff to fill in for callouts. Administrator stated all MedTech positions are hired as dual MedTech/caregiver positions and are trained accordingly.

Based upon observations, interviews, and record review we have found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations/complaint is 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: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2