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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 10/30/2025
Date Signed: 10/30/2025 11:53:24 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
08/07/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250807114706
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: DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan Whinery, AdministratorTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Personal Rights
Staff did not return authorized representatives calls
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Administrator, Morgan Whinery.

During the course of this investigation LPA made observations, conducted interviews, and reviewed records.

Personal Rights – Reporting Party (RP) alleges that Licensee does not ensure that residents are provided toilet paper or soap, and that Licensee did not replace resident key in a timely manner. Interview with RP indicated that resident (R1) has not been provided with toilet paper since admission and has been made to use paper towels for personal hygiene. Interview with Assistant Executive Director indicated that facility does not provide residents with toilet paper or soap unless residents run out and responsible parties are not able to fill supplies in a timely manner.

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

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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
Control Number 21-AS-20250807114706
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: 10/30/2025
NARRATIVE
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Continued from LIC9099...
Interview with Administrator indicated that facility does provide residents with toilet paper but does not provide soap unless responsible parties are unable to. Interview with Administrator indicated that upon loss of an apartment key, a work order is submitted and will be filled within twenty-four (24) hours. Review of R1 care notes indicated that apartment key was lost for at least five (5) days with the first entry of a lost key stating “door key has been gone for a while”. Care notes document staff explaining to R1 that key will be replaced soon, but no entry regarding replaced key was made following the last entry mentioning the lost key on the fifth (5th) day. Care notes indicated that staff would lock apartment door for R1 but R1 was not satisfied by this.

Staff did not return authorized representatives calls – RP alleges that facility did not return phone calls to authorized representative in a timely manner after an incident involving R1. Interview with RP indicated that it took twelve (12) days for facility to return phone calls requesting updates on the health of R1 following an incident that resulted in physical injury. RP states that several staff members directed RP to other staff members who would not or could not answer questions. Per RP, staff stated there was only one staff member who could provide the answers needed, but did not inform RP that this staff member would be out for an extended period of time. Review of Resident Notes indicated that calls with responsible parties are not noted aside from initial incident reporting.

Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid.

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. See LIC9099D.


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

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

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20250807114706
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: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2025
Section Cited
CCR
87307(a)(3)(D)
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Personal Accommodations and Services
87307(a)(3)(D) Hygiene items of general use such as soap and toilet paper.
This requirement not met as evidenced by:
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Administrator stated they would discuss with house keeping and implement soap dispensation immediately. Administrator would submit statement of implementation by Plan of Correction due date of 11/28/2025.
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Licensee did not ensure resident was supplied with basic hygeine items as outlined in Title 22 regulations
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Type B
11/28/2025
Section Cited
CCR
87468.1(a)(9)
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Personal Rights of Residents in All Facilities
87468.1(a)(9) To have communications to the licensee from their representatives answered promptly and appropriately.
This requirement not met as evidenced by:
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Administrator stated they would conduct an -inservice communication and reporting requirements training with reception and leadership team and will submit proof by Plan of Correction due date of 11/28/2025.
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Licensee did not ensure representative communications were answered promptly as representative was made to wait twelve (12) days to receive a call back regarding resident health and safety.
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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: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/07/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250807114706

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: DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Morgan Whinery, AdministratorTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Due to lack of supervision, resident assaulted another resident resulting in bruises
Resident bathroom is not kept sanitary
Staff did not notice resident's change in condition.
Staff are not following residents incontinence plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegations and met with Administrator, Morgan Whinery.

During the course of this investigation LPA made observations, conducted interviews, and reviewed records.

Due to lack of supervision, resident assaulted another resident resulting in bruises – Reporting Party (RP) alleges that resident (R1) was assaulted by resident (R2) in the facility due to lack of staff supervision. Review of SOC341 received by Community Care Licensing (CCL) indicated that R1 received bruising and was sent to the hospital due to assault from R2. SOC341 indicated that staff immediately intervened to redirect R2 and ensure the safety of all parties. Review of staff schedule did not indicate lack of staff in Memory Care. Interview with Administrator indicated that neither of the residents involved were on 1-to-1 staffing ratios.
Continued LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250807114706
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: 10/30/2025
NARRATIVE
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Continued from LIC9099A...

Staff did not notice resident's change in condition – RP alleges that staff did not notice change in condition resulting in UTIs and increased weight gain. Interview with RP indicated that R1 gained approximately forty-eight (48) pounds over the course of three (3) years and was diagnosed with two (2) UTIs. Review of weight log indicated that the weight gain did occur. Review of care notes indicated that UTIs were monitored and R1 was sent out to the hospital. Further review of care notes indicated that R1’s health status was being tracked and monitored. Several care note entries did not share unique information and were identical to previous entries over the course of various days.

Resident bathroom is not kept sanitary – RP alleges that R1 bathroom is not regularly cleaned resulting in staining and odors. Interview with RP indicated that they observed unhygienic conditions in R1 bathroom on numerous occasions and would inform facility management, but conditions did not change. Interview with Administrator indicated that rooms receive cleaning once a week as well as any other cleaning required by residents. Facility housekeeping does not keep a notes log of services rendered. Review of care notes indicated that staff logged room/bathroom checks for R1 and did not note any odors or staining.

Staff are not following residents incontinence plan – RP alleges that staff did not change R1 incontinence pads on a regular basis resulting in UTIs. Reviews of Functional Evaluation and Negotiated Service Plan for R1 indicated that R1 did require incontinence care. Review of care notes did not indicate entries in regard to incontinence plan. Interview with Administrator indicated that incontinence care is only noted for residents on scheduled incontinence plans and is not logged on care notes. Review of R1 Resident Monthly Assignment Report for the month of September 2025 indicated that staff provided assistance to/from bathroom and assisted with incontinence products on regularly scheduled intervals.

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: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5