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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 02/23/2026
Date Signed: 02/23/2026 03:34:33 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
11/25/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20251125154048
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: 159DATE:
02/23/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:May Ramos, Assistant Executive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Unqualified staff provide medical care to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegation and met with Assistant Executive Director, May Ramos.

Throughout the course of this investigation LPA made observations, conducted interviews, and reviewed documents.

Unqualified staff provide medical care to residents – Reporting Party (RP) alleges that staff are administering injections without the qualifications to do so. Interviews with five (5) out of nine (9) staff indicated that non-nursing staff were giving injections without using hand-over-hand procedures. Further interviews with these staff indicated that they were not aware of hand-over-hand injection procedures and had been trained to give injections themselves upon starting at the facility.

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

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
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 5
Control Number 21-AS-20251125154048
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: 02/23/2026
NARRATIVE
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Continued from LIC9099...

Interviews with two (2) out of nine (9) staff indicated that hand-over-hand injections are used. Interviews with three (3) out of nine (9) staff indicated that many Assisted Living residents are not capable of or will refuse to follow hand-over-hand procedures. Review of in-service training logs dated 12/4/25 and 12/25/25 indicated that training on hand-over-hand injections has since been given. Interviews with three (3) out of nine (9) staff indicated they were not aware any trainings have been held or were told to sign the in-service log without attending the training. Based upon evidence gathered, 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 Assistant Executive Director, whose signature on form confirms receipt.

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

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20251125154048
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: 02/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2026
Section Cited
CCR
87629(b)(1)
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87629 Injections
(b)... licensees who admit or retain residents who require injections...(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.
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Assistant Executive Director and Health and Wellness Director shall submit self-certifications of their understanding that non-skilled staff shall not administer injections by Plan of Correction due date of 2/24/2026 by 5:00PM to Community Care Licensing.
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This requirement not met as evidence by:
Five out of Nine staff interviewed indicated non-skilled staff did not receive proper training on injections which poses/posed an immediate health and safety or personal rights risk to residents 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: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
11/25/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20251125154048

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: 159DATE:
02/23/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:May Ramos, Assistant Executive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Insufficient Staffing
Staff did not follow resident’s prescribed medication orders
Facility is not following infection control procedures
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a complaint investigation and deliver findings regarding the above allegation and met with Assistant Executive Director, May Ramos.

Throughout the course of this investigation LPA made observations, conducted interviews, and reviewed documents.

Insufficient Staffing – Reporting Party (RP) alleges that facility is chronically understaffed leading to staff falling behind on duties. Review of Memory Care and Assisted Living staff schedules for November and December indicated approximately ten (10) care staff on day shift and approximately seven (7) care staff on night shift per side. Interviews with three (3) of eight (8) staff indicated that short staffing occurs on days with callouts resulting in single staff members covering full floors.Interviews with management indicated that there are no staffing concerns and the facility is currently fully staffed with enough backstaff to fill in for callouts.
Continued LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
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-20251125154048
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: 02/23/2026
NARRATIVE
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Continued from LIC9099A...
Interview with one (1) out of five (5) residents indicated that there is an ongoing issue with low staffing due to callouts without backup. Interviews with four (4) out of five (5) residents indicated that staff are friendly and helpful with enough staff to provide assistance and care.

Staff did not follow resident’s prescribed medication orders – Reporting Party (RP) alleges that staff do not administer medication to residents at their prescribed times. Interview with three (3) of eight (8) staff indicated that there is a lack of medcarts in the facility leading to too many residents being assigned to each individual cart, making it difficult to deliver medications on time. Interview with one (1) of eight (8) staff indicated that residents have reported hearing management rush staff over walkie-talkies during medication passes leading to resident anxiety. Interviews with three (3) of five (5) residents indicated that they receive their medications on time and have not experienced delays. Interview with one (1) of five (5) residents indicated that they will occasionally have to request their medication be given. Interview with one (1) of five (5) residents indicated that they did not receive their breakfast medication until lunch. Reviews of ten (10) Assisted Living and ten (10) Memory Care Medication Administration Records (MARs) indicated that medication is being logged as administered per prescribed orders. Resident refusals are logged onto the Note page as well faxes to physicians.

Facility is not following infection control procedures – Reporting Party (RP) alleges that residents with communicable or infections disease are being retained without use of proper infection control. Interviews with two (2) of eight (8) staff indicated that there have been numerous instances of residents being diagnosed with Clostridium Difficile (C.diff) and Methicillin-resistant Staphylococcus Aureus (MRSA) being retained in the facility. During this investigation, LPA was made aware that a resident (R1) was currently diagnosed and residing in the facility with a diagnosis of MRSA. LPA observed cabinets containing PPE outside of R1’s room for staff use. Interviews with five (5) of eight (8) staff indicated that they were not aware of R1s exact diagnosis, however, they were donning PPE as a whiteboard in the staff room stated R1 had an infectious skin disease. Review of Incident Report received by Community Care Licensing on 2/4/2026 indicated resident was diagnosed on 1/31/2026 and the facility requested an exception to retain a resident with a restricted health condition on 2/4/2026. Review of in-service documents indicated that a training was held on 1/30/2026 on providing care to MRSA positive residents. 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 are unsubstantiated.

No deficiencies cited. Exit interview conducted with Assistant Executive Director, whose signature on form confirms receipt.

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

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5