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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 02/03/2026
Date Signed: 02/03/2026 03:05:02 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
09/29/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250929084229
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: 164DATE:
02/03/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jesse Sias, Regional Director of OperationsTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility did not seek timely medical
Staff did not respond to call button timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias.

Licensing Program Analyst (LPA) Magdaleno conducted an investigation into the allegations of “facility did not seek timely medical” and “staff did not respond to call button timely”. LPA interviewed staff, outside parties, reviewed facility records, hospital records and county records. Based on interviews with seven (7) facility staff, five (5) out of seven (7) indicated that resident R1’s call bell had been ringing for more than one (1) hour and two (2) staff indicated the bell rang for more than four (4) hours, they all indicated the call bell ringing was showing “invalid zone” or “invalid user” on their phones and they confirmed the ringing was coming from R1s room.

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

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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 4
Control Number 21-AS-20250929084229
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: 02/03/2026
NARRATIVE
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Continued from LIC9099...

The seventh staff interviewed indicated the pendant was ringing and staff responded to it. Interviews of management revealed that R1 returned the morning of September 4, 2025, to the facility from an ER visit for a UTI the day prior (September 3, 2025), staff were informed that while previously independent, R1 was now on 72-hour checks (as facilities protocol).

Four (4) of the seven (7) staff interviewed stated they were not aware R1 required increased monitoring and two (2) of the seven (7) were unaware that the resident had returned from the hospital. The Care Plan for R1 had not been updated since April 29, 2025, the April Care Plan indicates under line item titled “Status Checks” that “Resident is okay with status checks during the day and no status checks at night”. Staff interviewed stated they were not verbally informed of increased monitoring of R1.

According to electronic chart notes, R1 was checked September 4, 2025, at 8:36pm, notes indicate, “resident reports ongoing abdominal pain… reminded to use call pendant if pain increases or assistance is needed”. Electronic entry on 9/5/2025 at 3:34 AM indicates “resident is in room with no complaints of pain or discomfort during this shift”. Next electronic entry is 9/5/2025 1:59pm which indicates R1 was found at 8:15am unresponsive. Staff interviewed stated that there were issues with the call bells in a specific zone of the building and management was previously informed of this. Based on evidence received during the investigation the above allegations are SUBSTANTIATED.

**An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).**

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. See LIC9099D. Appeal rights were provided.

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: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
09/29/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250929084229

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:
02/03/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jesse Sias, Regional Director of OperationsTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Regional Director of Operations, Jesse Sias.

Questionable Death - Licensing Program Analyst (LPA) Magdaleno conducted an investigation into the allegation of questionable death. LPA interviewed staff, outside parties, reviewed facility records, hospital records, and county records. Based on the information received during the investigation resident R1’s death was not questionable. 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.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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 4
Control Number 21-AS-20250929084229
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: 02/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2026
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement not met by Licensee as evidenced by:
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Deficiency cleared at time of visit, civil penalty assessed in the amount of $500.
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R1 alarm pendant was activated and rang for more than 1 hour as "invalid zone" before R1 was discovered.
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Type A
02/04/2026
Section Cited
CCR
87466
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87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…
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Deficiency cleared at time of visit,
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This requirement not met by Licensee as evidenced by:
Facility staff were not informed of additional checks to completed for R1 following hospital discharge.
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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: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4