486803806-12-4-2025-21-AS-CMAZ-DP6UK9-20251208143847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 12/04/2025
Date Signed: 12/04/2025 02:48:40 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
10/28/2025 and conducted by Evaluator Elias Magdaleno

COMPLAINT CONTROL NUMBER: 21-AS-20251028124611

FACILITY NAME:	VILLAGE AT RANCHO SOLANO ASSISTED LIVING, THE		FACILITY NUMBER:	486803806
ADMINISTRATOR:	WHINERY,MORGAN		FACILITY TYPE:	740
ADDRESS:	3350 CHERRY HILLS COURT		TELEPHONE:	(707) 425-3588
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	250	CENSUS: 164	DATE:	12/04/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Jesse Sias, Regional Director of Operations		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff neglect resulted in resident injury
Staff are not properly trained to use hoyer lift

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 Regional Director of Operations, Jesse Sias.

Staff neglect resulted in resident injury – Reporting Party (RP) alleges that resident (R1) was being transferred via hoyer lift by staff when they fell to the floor breaking their femur. RP also alleges a separate incident in which R1 was being transferred via hoyer by staff when the hoyer lift fell and hit R1’s head. During this investigation CCL staff made observations, reviewed records, and conducted interviews. On 09/14/2025, two staff (S1, S2) were helping R1 move from their bed to their wheelchair. R1 stated the staff “were helping as usual” when they asked, “is it close enough to sit?” R1 stated they “could have sworn the staff said yes” and R1 went to sit. R1 ended up sitting down on the edge of the wheelchair, which caused them to slide down and hit the footplate of their wheelchair.
Continued LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251028124611

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: 12/04/2025

NARRATIVE

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Continued from LIC9099...

R1 then “bounced onto the floor.” R1 refused medical treatment and felt minimal pain. R1’s primary care doctor was notified and scheduled an X-ray appointment for R1 a week after the incident, which revealed a femur fracture. R1 reported that they had never had any other concerning incidents or falls during transfers. Facility staff claim that R1’s fall was due to their legs “buckling,” a condition they acknowledge has happened before. However, R1 maintains that on 09/14/2025, they fell solely because they believed someone had assured them it was safe to sit down. During a transfer on 10/22/2025, staff (S3, S4) did not correctly set up the Hoyer lift, causing it to tip over. As a result, R1 was dropped onto their bed and struck in the head by the Hoyer lift. S3 received a written reprimand due to the incident.

Staff are not properly trained to use hoyer lift – Reporting Party (RP) alleges that facility staff are not properly trained to use the hoyer lift. Review of facility records indicated that the incident that occurred on 09/14/2025 did not include a hoyer lift, S1 and S2 were providing a 2-person assist to R1. Review of training documents dated 10/22/2025 show two separate training's, one at 0930 and the other at 1330, in order to include staff on different shifts, both training documents included the attendance signatures for S3 and S4. Interview with S3 indicated that the day of the hoyer lift training it was busy on the floor and S3 was not sure they were able to sit through the whole thing. On 10/28/2025 S3 and S4 received 1 on 1 retraining on hoyer lift operation and on 10/29/2025 the facility held a live demonstration on hoyer lift operation led by a hospice agency.

Although the allegations may have happened or are valid, the Department has found 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 Regional Director of Operations, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC9099 (FAS) - (06/04)

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