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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 11/20/2025
Date Signed: 11/20/2025 03:30:29 PM

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
09/10/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250910094420
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: 181DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Morgan Whinery, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Morgan Whinery.

Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner. – Reporting Party (RP) alleges that resident call lights go unanswered for 30 minutes or more when staff are busy providing care and management does not provide support. Over the course of this investigation LPA made observations, conducted interviews, and reviewed records. Review of Response Time Report for Pendant Alarms/Bath E-Calls over the course of three (3) days showed thirty-three (33) instances of thirty (30) minutes or longer, five (5) instances of one (1) hour or longer, and one (1) instance of two (2) hours or longer response times. LPA also observed a resident report to facility reception that a call pendant went unanswered for fifty-four (54) minutes. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid.
Continued LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
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 7
Control Number 21-AS-20250910094420
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: 11/20/2025
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. 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: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20250910094420
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: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs... This requirement not met by licensee as evidenced by:
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Administrator stated they would provide in-service training logs regarding answering alarms in a timely manner by Plan of Correction due date of 12/19/2025. Additional alarm phones have also been ordered.
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Based on a review of Response Time Report for Pendant Alarms/Bath E-Calls showed 39 instances of Pendant Alarms/Bath E-Calls going unanswered for 30 minutes to 2 plus hours which posed/poses a potential 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: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
09/10/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250910094420

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: 181DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Morgan Whinery, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee does not ensure that staff meet residents' care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Morgan Whinery.

Licensee does not ensure that staff meet residents' care needs. – Reporting Party (RP) alleges that resident care needs are not being met due to overworked staff. Review of staff daily schedules indicated two (2) care givers per floor and two (2) medtechs for AM and PM shift with AM having one (1) additional float staff. Noc shift is staffed with one (1) care giver per floor on average and one (1) medtech, with an occasional extra care giver assigned to the third floor. Review of a sample of Resident Monthly Assignment Reports for Assisted Living (AL) and Memory Care (MC) indicated resident tasks being completed for one (1) and two (2)-person assisted residents. Interviews with staff indicated that there is a lack of call phones to answer resident alerts and a lack of facility keys to be used during resident checks.

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

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
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 7
Control Number 21-AS-20250910094420
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: 11/20/2025
NARRATIVE
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Continued from LIC9099A...

Further interviews with care givers indicated that they feel as if they are unable to meet some resident needs such as scheduled bathing in a timely manner due to lack of support during busy times. Interviews with residents indicated that they are provided the care they need and staff are helpful when called upon. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation 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: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
09/10/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250910094420

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: 181DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Morgan Whinery, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Untrained staff are providing care and supervision to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unnanounced to continue a complaint investigation and deliver findings regarding the above allegation(s) and met with Administrator Morgan Whinery.

Untrained staff are providing care and supervision to residents in care. – Reporting Party (RP) alleges that staff are providing care to residents before receiving proper training. Over the course of this investigation LPA made observations, conducted interviews, and reviewed records. Review of training documents and facility New Hire Onboarding & Training Rollout indicated that staff complete required online training before they are evaluated and a decision is made to allow them to either continue forward with shadow training or retake online training. Further review indicated a five (5) step training plan that included various required check-ins with management to ensure competency.

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

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
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 7
Control Number 21-AS-20250910094420
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: 11/20/2025
NARRATIVE
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Continued from LIC9099A...

Interview with Administrator indicated that facility maintains compliance with regulation by requiring hands-on shadow training under the supervision of fully trained staff. Interviews with staff indicated they are assigned shadow partners to conduct hands-on training after initial online training is completed. 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: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7