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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803806
Report Date: 03/12/2026
Date Signed: 03/12/2026 02:53:42 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
12/03/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20251203165925
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: 168DATE:
03/12/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ieshaa Ragland, Health and Wellness DirectorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility is not meeting resident's care needs
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 Health and Wellness Director, Ieshaa Ragland.

Facility is not meeting resident's care needs – Reporting Party (RP) alleges that facility is neglecting resident (R1) and is not providing the care R1 requires. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Interview with management indicated that R1 had a “small, diabetic ulcer on their toe” that was difficult to see and was noticed by staff “while assisting resident with their socks/shoes”. Further interviews with management indicated that upon reassessment at the hospital they were informed that R1’s toe had been amputated. Interview with Witness (W1) indicated that R1 had developed a toe ulcer “due to negligence” and was not being bathed properly.

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

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
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-20251203165925
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: 03/12/2026
NARRATIVE
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Continued from LIC9099...

Further interview with W1 indicated that R1 “finally stated they had pain in toe. It takes a lot for a dementia person to realize something is wrong” and when staff checked the toe there was an open and weeping ulcer. Upon assessment at the hospital it was found the ulcer had turned necrotic which had reached the bone and required a partial amputation. Review of Resident Notes indicated that toe sore was initially observed on 12/02/2025 and R1 was taken to the hospital by their Responsible Party on 12/05/2025 where R1 was admitted and subsequently had their toe partially amputated. Review of five (5) Resident Shower Sheets for R1 indicated two (2) shower/body check refusals and three (3) successful showers and body checks. Three (3) of three (3) successful body checks indicated that R1 was visually assessed for lesions/blisters/abnormal skin and did not require their toenails to be cut. Review of photographs submitted indicated R1’s toenails had grown past the edge of their toe and were curling down. Further review of photographs indicated that R1’s toe had substantial amounts of slough, was weeping fluid, and had turned a yellow/black color. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is 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 Health and Wellness Director, whose signature on form confirms receipt.

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

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20251203165925
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: 03/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2026
Section Cited
CCR
87465(a)(2)
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87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs...
This requirement not met by licensee as evidenced by:
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Licensee will submit self-certification regarding adherence to the regulation cited as well as in-service training for staff on completing, documenting, and escalating resident body checks when required by Plan of Correction due date of 3/13/2026 by 5:00pm.
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Resident (R1) did not receive adequate body checks that resulted in partial amputation of their big toe from an ulcer which poses/posed an immediate 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: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
12/03/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20251203165925

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: 168DATE:
03/12/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ieshaa Ragland, Health and Wellness DirectorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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2
3
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5
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7
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9
Facility is not observing resident's change of condition
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 Health and Wellness Director, Ieshaa Ragland.
Facility is not observing resident's change of condition – Reporting Party (RP) alleges that facility did not properly inspect resident’s (R1) body leading to ulcers going unnoticed. Review of Resident Notes indicated that an open sore was observed on 12/02/2025 and was cleaned by facility nurses, R1’s physician and responsible party were documented as notified. Entry made on 12/04/2025 indicated that sore had a foul odor and slough with facility contacting home health services requesting a visit, a doctor’s appointment was indicated to have been made by R1’s responsible party for 12/05/2025. Review of email correspondence from the facility indicated that R1 left the facility to attend doctor’s appointment on 12/05/2025 and was admitted for further care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.No deficiencies cited. Exit interview conducted with Health and Wellness Director, whose signature on form confirms receipt.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
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 4