Inspection Reports for The Village at Rancho Solano

The inspection was an unannounced complaint investigation triggered by an allegation that the facility was not following a resident's care plan after a change in condition requiring increased checks.

The investigation substantiated the allegation that the facility failed to follow the resident's care plan, missing three nighttime status checks during a 10-day fall intervention plan, including one instance where 22 hours and 40 minutes elapsed between checks, posing a potential health and safety risk.

The complaint was substantiated based on interviews, observations, and record reviews showing missed resident checks during a fall intervention period. The allegation was that the facility did not follow the resident's care plan after a change in condition requiring increased monitoring.

Unannounced case management incident visit to follow up on a self-reported allegation of sexual abuse.

No deficiencies were cited during the visit. Licensing Program Analyst obtained interviews and documentation related to the allegation and requested the facility to submit required reports and continue updates.

Visit was triggered by a self-reported allegation of sexual abuse. Licensing Program Analyst obtained interviews with the alleging resident, spouse, and staff, as well as chart notes and internal emails. Facility was asked to submit SOC341 and Special Incident Report and to continue updating Community Care Licensing on developments.

The visit was conducted as an unannounced case management - incident visit to gather further information regarding a Death Report submitted by the facility on 2025-09-12.

No deficiencies were cited during the visit. Interviews and document reviews were conducted, and an exit interview was held with the Administrator.

An unannounced complaint investigation was conducted in response to allegations that a resident was placed in memory care without their consent and did not meet memory care requirements.

The investigation found that although the resident did not have a dementia diagnosis and was able to care for themselves, the resident's Power of Attorney had authority to make medical decisions including placement. There was insufficient evidence to substantiate the complaint, and no deficiencies were cited.

The complaint was unsubstantiated. Allegations included improper placement of a resident in memory care without consent and lack of access to communication devices or visitors. The investigation included interviews, record reviews, and observations.

An unannounced complaint investigation was conducted following a complaint received on 2025-09-02 alleging verbal abuse of a resident by staff.

The investigation included observations, record reviews, and interviews with residents and staff. No evidence was found to substantiate the allegation of verbal abuse, and the complaint was determined to be unsubstantiated.

The complaint alleged verbal abuse of resident R1 by staff. Interviews with R1, roommates, and other residents did not confirm the allegation. The Health and Wellness Coordinator stated staff rotation practices. Review of care plans and notes showed no reports of abuse. The allegation was unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were mismanaging a resident's medication and inappropriately increasing a resident's rent.

The investigation substantiated the allegation that staff mismanaged resident medication, with one resident missing fourteen doses over 31 days due to refill errors, posing an immediate health risk. The allegation regarding inappropriate rent increase was found to be unfounded, as the rate increase applied facility-wide and was not related to care needs.

The complaint investigation was substantiated for medication mismanagement, with evidence showing missed medication doses and refill errors. The rent increase allegation was unsubstantiated.

An unannounced complaint investigation was conducted due to allegations that staff did not follow a resident’s prescribed medication orders, specifically administering higher dosages than ordered.

The investigation substantiated that staff administered multiple doses of medication in under 24 hours on five occasions, including three occasions where a full pill was given instead of the prescribed half dose, posing an immediate health and safety risk.

The complaint was substantiated based on observations, record review, and interviews. The allegation involved staff not following prescribed medication orders, administering higher dosages than ordered. A civil penalty for a repeat violation was noted.

The document does not contain any inspection or regulatory information; it only shows an error message.

No findings or content available due to error message in the document.

The inspection was a case management visit conducted to obtain more information regarding a self-reported incident involving the death of a resident at the hospital.

No deficiencies were cited during the visit. The Licensing Program Analyst requested copies of the coroner's report, which the Administrator stated would be sent when released by the hospital.

The visit was triggered by a self-reported incident report received on 2025-09-02 involving the death of a resident (R1) at the hospital. The Licensing Program Analyst conducted the visit to gather more information and requested the coroner's report.

An unannounced complaint investigation was conducted in response to an allegation that the facility administrator did not have an active administrator certification.

The investigation found that the administrator, Morgan Whinery, has a current and active certification valid from 09/18/2024 to 09/17/2026. The complaint allegation was determined to be unfounded and no deficiencies were cited.

The complaint alleged that the facility administrator did not have an active administrator certification. This allegation was found to be unfounded after verification with the Administrator Certification Bureau.

Unannounced complaint investigation visit conducted due to allegations that facility staff were not adhering to proper food service guidelines, specifically regarding dating and rotation of incoming food and beverage products.

The investigation found that food was generally labeled, dated, and stored in compliance with regulations, with minor observations such as unlabeled and uncovered cake slices explained as part of ongoing meal service. A photo showed molded hot peppers which were discarded before serving. Based on observations, interviews, and record review, there was insufficient evidence to substantiate the allegations, and no deficiencies were cited.

Complaint was unsubstantiated due to lack of preponderance of evidence proving the alleged violations occurred. The complaint involved food service guideline adherence and food safety concerns.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff does not ensure the facility is free of rodents.

The investigation found no evidence of rodents during the visit, with pest control reports showing no captures or activity. Although there were allegations and some reports of rodents, the facility had taken corrective actions such as installing draft blockers and ordering a screen door. The complaint was determined to be unsubstantiated with no deficiencies cited.

The complaint alleged that rats were present in a resident's room and that the facility was not taking proper actions to address the issue. The investigation included observations, interviews, and record reviews. The complaint was found to be unsubstantiated due to lack of preponderance of evidence.

Unannounced complaint investigation conducted due to allegations that staff do not timely respond to residents' alerts and that residents are left unattended.

The investigation found no preponderance of evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that while some residents and staff expressed concerns about response times and staffing levels, no deficiencies were cited and the complaint was unsubstantiated.

Complaint was unsubstantiated after investigation. Allegations included delayed response to resident call buttons and residents being left unattended due to understaffing. Evidence did not prove violations occurred.

The inspection was conducted as a case management visit to obtain more information regarding an Incident Report received on 2025-08-13 involving a resident being sent to the hospital and subsequent transfer to a skilled nursing facility.

No deficiencies were cited during the visit. The Licensing Program Analyst obtained copies of the resident's care plan and face sheet and conducted an exit interview with the Administrator.

The visit was triggered by an incident report involving a resident (R1) who was sent to the hospital and then transferred to a skilled nursing facility. No deficiencies were found related to this incident.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-04-14 regarding staff mismanaging residents' medications and other care concerns.

The complaint that staff were mismanaging residents' medications was substantiated due to medication errors involving two residents. Other allegations including inadequate supervision, improper staff training, bed bug infestation, infectious disease protocol violations, and improper resident assessments were found to be unsubstantiated or unfounded. No deficiencies were cited except for the medication error.

The complaint investigation was substantiated for medication mismanagement involving two residents (R1 and R2). Other allegations including inadequate supervision resulting in resident elopements, improper staff training for catheter care, bed bug infestation, infectious disease protocol violations, and improper resident assessments prior to admission were unsubstantiated or unfounded based on interviews, record reviews, and observations.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility unlawfully evicted a resident and that staff retaliated against a resident.

The investigation found that the allegations were unsubstantiated. Documentation and interviews showed multiple resident altercations, with interventions attempted by the facility, but there was insufficient evidence to prove unlawful eviction or retaliation.

The complaint alleged unlawful eviction of a resident and staff retaliation. The investigation reviewed Special Incident Reports from January 2023 to May 2025, identifying 34 incidents involving 23 residents. Three residents had multiple altercations; one resident was evicted due to aggressive behavior with documented incidents. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not ensure residents are able to come and go freely and that staff are limiting residents' visits.

The investigation found that while some residents waited 5-6 minutes to be let in after hours and calls sometimes went to voicemail, there was no preponderance of evidence to substantiate the allegations. The facility locks the front doors at 5:30pm at the request of some residents concerned about safety, and visitors are instructed to call an after-hours phone for entry. No deficiencies were cited.

The complaint alleged that the facility locks the front doors at 5:30pm restricting residents' freedom of movement and limiting visits. Interviews with residents, family members, and the administrator revealed no substantiated issues. The complaint was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not properly assessing residents in care and not providing adequate food service to residents.

The investigation found that the allegations regarding improper resident assessment and inadequate food service were unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.

The complaint alleged that a resident's care level was raised without assessment or consultation, and that food quality had declined, including a dinner meal served without teriyaki sauce due to dietary restrictions. Interviews and record reviews did not substantiate these allegations.

Unannounced complaint investigation conducted due to allegations that the licensee did not ensure proper food safety protocols and was not preventing rodents from being in the facility.

The investigation found that food safety protocols were being followed, including proper labeling, dating, and storage of food, and temperature logs were maintained. No evidence of rodents or vermin was observed, and pest control measures were in place. The allegations were unsubstantiated due to lack of preponderance of evidence.

Complaint alleged improper food safety practices such as undated food, improper storage, expired water filters, malfunctioning cooking equipment, falsified temperature logs, and lack of sanitizer pH testing. Also alleged presence of rats in the kitchen. Investigation found no evidence to substantiate these claims.

An unannounced complaint investigation was conducted regarding the allegation that staff were not following the general food service requirements.

The investigation found that menu postings were visible and staff communicated last-minute menu changes due to supplier delivery issues. Resident interviews provided conflicting information about the frequency of unavailable menu items. No evidence supported a violation, and the allegation was unsubstantiated.

The allegation was that staff were not following general food service requirements, specifically that dining menus were posted but changed daily without notice, constituting false advertisement. The complaint was unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced case management inspection conducted to follow up on a self-reported medication error that occurred on 2025-05-16 involving a medication technician dispensing oral antibiotics instead of the prescribed topical antibiotic.

The inspection found a medication error that posed an immediate health, safety, or personal rights risk to a resident. The facility submitted an incident report and corrective actions were reviewed. No adverse reactions were observed in the resident.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not following a resident's care plan and were not ensuring residents' personal rights.

The investigation found no evidence to substantiate the allegations. Staff were found to be following the resident's care plan appropriately, and there was no violation regarding residents' personal rights after implementation of door key management in the memory care unit.

The complaint investigation was unsubstantiated. Allegations included staff not following a resident's care plan and not ensuring residents' personal rights. The Licensing Program Analyst conducted multiple visits, interviews, and document reviews but was unable to find evidence of violations.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2025-03-19 regarding staff responses to Resident Council concerns, posting of Resident Council meetings, and presence of a staff liaison to assist the Resident Council.

The investigation found all allegations to be either unfounded or unsubstantiated. Staff responded to Resident Council concerns in writing within an appropriate timeframe, Resident Council meeting notices were posted in multiple central locations, and the Executive Director serves as the staff liaison to the Resident Council.

The complaint included three main allegations: 1) Staff did not respond in writing to Resident Council concerns within the required timeframe; 2) Staff did not post Resident Council meeting notices in a central location; 3) There was no staff liaison to assist the Resident Council. The first two allegations were found to be unfounded, meaning the allegations were false or without reasonable basis. The third allegation was unsubstantiated, meaning there was insufficient evidence to prove or disprove the allegation.

An unannounced complaint investigation was conducted regarding an allegation that staff did not provide resident medication as needed.

The investigation found that the resident was administered PRN medication on 4/24/2025 and there was no record of a PRN request on 4/25/2025. Staff interviews and record reviews indicated that PRN medications were administered appropriately. The allegation was determined to be unsubstantiated due to insufficient evidence of a violation.

The complaint alleged that staff did not provide resident medication as needed. The allegation was unsubstantiated after investigation, as there was not a preponderance of evidence to prove the violation occurred.

The visit was conducted as a case management review of a self-reported incident involving a resident (R1) who expressed thoughts of self-harm, following an incident report received on 2025-03-19.

The Licensing Program Analyst reviewed records and the facility's plan to ensure the care and supervision of the resident. No deficiencies were cited during the visit.

The visit was triggered by a self-reported incident report indicating that resident R1 expressed thoughts of self-harm. The case management review found no deficiencies.

The visit was an unannounced office Non-Compliance Conference conducted to review concerns identified by the Community Care Licensing Agency, including multiple complaint investigations and issues related to personnel requirements, medication discrepancies, personal rights, elopements, and call bell response times.

No deficiencies were cited during the Non-Compliance Conference. The report summarizes ongoing investigations and concerns but does not document any new deficiencies.

Community Care Licensing Agency investigated 14 complaints in 2024 and 6 complaint investigations in 2025, with 2 substantiated and 4 still under investigation.

Unannounced visit/investigation of a complaint received on 01/07/2025 regarding alleged failure to properly notify resident or representative of rate increase and failure to maintain facility cleanliness.

The investigation found that the facility provided proper notice of rate increase to the resident, and the facility was found to be clean and sanitary during multiple unannounced visits. There was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.

Complaint was unsubstantiated based on statements, documents, and observations. Allegations included failure to notify resident or representative of rate increase and failure to maintain facility cleanliness.

Unannounced visit/investigation of a complaint received on 2025-02-21 regarding personal rights violations at the facility.

The investigation substantiated that Resident R2 repeatedly entered Resident R1's space and bed, violating R1's personal rights as evidenced by videos and witness statements. Facility staff had attempted hourly wellness checks to prevent this.

Complaint was substantiated based on videos and statements showing Resident R2 entering Resident R1's bed uninvited, compromising R1's personal rights.

The inspection was an unannounced complaint investigation triggered by an allegation that facility staff did not follow physician's orders in a timely manner.

The allegation that facility staff did not follow physician's orders in a timely manner was substantiated. Records and interviews confirmed a 12-day delay in obtaining a urine culture test for a resident due to miscommunication.

The complaint was substantiated based on evidence that staff delayed following a physician's order for a urine culture test by 12 days due to miscommunication.

The inspection was an unannounced continuation of a 1 Year Required Visit (annual inspection) to evaluate compliance with regulations for an assisted living and memory care facility.

The inspection found that resident care plans and medical assessments were up to date and well organized. However, personnel records were not readily available for review, posing a potential health and safety risk. Additionally, a resident with dementia eloped from the facility due to an unarmed alarm door, which was cited as a deficiency but cleared during the visit after staff training and corrective actions.

The inspection was an unannounced complaint investigation triggered by allegations received on 12/04/2024 regarding staff not providing assistance for resident council meetings, untimely meal service, and failure to follow special diet orders, as well as missing required postings at the facility.

The investigation found the allegations about assistance to resident council meetings, meal service timeliness, and special diet compliance to be unsubstantiated based on interviews, document reviews, and multiple unannounced site visits. However, the allegation regarding missing required postings was substantiated, with a deficiency cited for failure to post personal rights and complaint information as required by regulation. The deficiency was corrected at the time of the visit.

The complaint investigation was unannounced and conducted by Evaluator David Leibert. The complaint control number is 21-AS-20241204123831. The allegations included failure to assist residents with council meetings, untimely meal service, failure to follow special diet orders, and missing required postings. The investigation included interviews, document reviews, and multiple unannounced site visits. The allegations about assistance, meal service, and diet were unsubstantiated, while the posting deficiency was substantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to prevent a physical altercation between residents, insufficient staffing, failure to provide adequate notice of rate increases, resident elopement due to neglect, and failure to follow reporting requirements.

The investigation found some allegations unsubstantiated, such as failure to prevent a physical altercation and insufficient staffing, but substantiated others including failure to provide timely written notice of rate increases, resident elopement without staff knowledge, and failure to follow reporting requirements. A civil penalty of $500 was issued for zero tolerance of absence of supervision.

The complaint investigation was unannounced and conducted due to allegations including failure to prevent a physical altercation, insufficient staffing, failure to provide adequate notice of rate increases, resident elopement due to neglect, and failure to follow reporting requirements. The investigation concluded some allegations were substantiated and others unsubstantiated.

The inspection was conducted as a required unannounced 1-year inspection of the assisted living facility.

The facility was generally found to be in compliance with regulations, including safe food handling, fire safety, and disaster drills. However, deficiencies were noted related to hot water temperatures exceeding regulatory limits and an unlocked laundry room with cleaning chemicals accessible to residents in memory care.

The inspection was an unannounced complaint investigation triggered by an allegation that Memory Care staff left residents unattended in the dining area on 11/26/2024.

The investigation included four unannounced site visits, document review, and interviews with family members and staff. The allegation was found to be unsubstantiated due to lack of preponderance of evidence despite some observations and statements.

The complaint alleged inadequate assistance to residents and that Memory Care staff left residents unattended in the dining area for a 10-minute period on 11/26/2024. The allegation was unsubstantiated after investigation.

The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were not providing residents with a reasonable amount of privacy in common areas due to video cameras recording audio as well as video.

The investigation substantiated the complaint that the facility had video cameras with audio activated in common areas, violating residents' personal rights. The audio function was deactivated on January 11, 2025, and the facility agreed to use video only going forward.

The complaint was substantiated based on statements from the complainant, the administrator, and observations by the Licensing Program Analyst. The audio function on cameras was activated without the administrator's initial knowledge and was turned off during the investigation.

The visit was an unannounced follow-up on an incident reported by the facility on 2024-11-06 involving a possible infection in a resident.

Staff assessed the resident and called 911 despite the spouse's objection. The resident was transferred to a medical facility and then to skilled nursing. No citations were issued during this visit.

An unannounced complaint investigation was conducted due to allegations that facility staff did not respond to residents' calls for assistance in a timely manner.

The investigation found that most calls were answered within 3-8 minutes, but multiple calls each day from 11/1/2024 through 11/15/2024 took between 15 to 31 minutes to be answered. Additionally, one bathroom pull cord was found non-responsive. The complaint was substantiated based on the preponderance of evidence.

The complaint alleging that facility staff did not respond timely to residents' calls for assistance was substantiated after review of call bell records, observations, and interviews. The evidence showed delayed response times and a non-responsive pull cord in a bathroom.

The visit was an unannounced Case Management inspection conducted in response to a self-reported incident involving a resident's allegation of rape.

The Licensing Program Analyst verified that local police, responsible party, and Ombudsman were notified regarding the incident. No citations were issued during this visit.

The complaint involved a resident in care reporting that they were raped. The allegation was substantiated by notification to local authorities and involved parties.

Licensing Program Analyst Leibert arrived unannounced to conduct a proof of correction visit to review the citation issued on October 01, 2024 for H&S 1569 and the documentation submitted by the Administrator.

The citation issued on October 01, 2024 for H&S 1569 was reviewed and found to be cleared based on the documentation submitted by the Administrator.

The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2024-10-28 regarding maintenance issues including resident shower maintenance, tripping hazards, and mold in the facility.

Two complaints were investigated: one regarding shower maintenance and tripping hazards which was unsubstantiated, and another regarding mold in a resident's shower which was substantiated based on photographs and statements. A deficiency was cited for failure to maintain the facility in a clean, safe, and sanitary condition due to mold.

The complaint investigation was triggered by allegations that facility staff were not ensuring resident shower maintenance, not ensuring the facility was free of tripping hazards, and not properly addressing mold in the facility. The shower maintenance and tripping hazard allegations were unsubstantiated, while the mold allegation was substantiated.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that facility staff were not meeting clients' dietary needs.

The investigation found that although the complainant suggested insufficient nutrition for Resident 1, the evidence was inconclusive. Resident 1's physician cleared them for a regular diet, and care notes showed a pattern of meal refusal or partial consumption. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that facility staff were not meeting clients' dietary needs. The allegation was investigated and found to be unsubstantiated.

An unannounced complaint investigation was conducted due to allegations that staff did not ensure reporting requirements were followed and that medications were not dispensed as prescribed or properly managed.

The investigation found that a medication error occurred on 10/14/2024 involving Resident 1 receiving an incorrect dose and medication not ordered. The medication administration record was inaccurate. The allegations were substantiated based on statements and documents. A deficiency was cited related to incidental medical care and medication administration.

The complaint alleged failure to follow reporting requirements and medication errors. The medication error was substantiated with evidence that Resident 1 received an incorrect dose and medication not ordered. The complaint regarding reporting requirements was found to be unfounded.

The inspection was an unannounced complaint investigation triggered by an allegation that the facility illegally evicted a resident who was refused return following hospitalization.

The investigation substantiated that the resident was illegally evicted when not allowed to return to the facility after hospitalization due to a medical condition that is not prohibited. The facility was cited for violating eviction procedures under California Code of Regulations.

The complaint alleged that the facility refused the return of resident R1 following hospitalization due to a prohibited condition. The investigation found that the resident's condition (use of a Perm-Cath CVC catheter) was not a prohibited condition and that the resident was illegally evicted. The allegation was substantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not meeting a resident's care needs, charging for services not provided, and that staff were not trained.

The investigation found that the resident had a pattern of refusal of care, the facility provided staff training records, and no evidence was found to prove or disprove the allegations. Therefore, the allegations were unsubstantiated.

The complaint alleged that the facility was not meeting resident R1's care needs, staff were not trained in Hoyer lift and Body Mechanics, and that R1 was charged for services not provided. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-08-22 regarding the facility's compliance with resident care, notification of rate increases, dietary orders, incident reporting, and billing practices.

The investigation found one allegation substantiated related to failure to provide detailed explanations and itemization of charges for additional services and failure to follow a resident's special diet, resulting in cited deficiencies. Other allegations, including failure to provide written notice of rate increase and failure to meet resident's incontinent care needs, were found unsubstantiated or unfounded. The facility was cited for deficiencies under California Code of Regulations and Health and Safety Codes with plans of correction required.

The complaint investigation was triggered by allegations including failure to provide written notice of rate increase, failure to meet resident's incontinent care needs, failure to follow dietary orders, failure to provide written incident reports, and failure to provide detailed explanations and itemization of charges. The allegation regarding rate increase notice was unfounded; incontinent care needs allegation was unsubstantiated; allegations regarding dietary orders, incident reports, and billing explanations were substantiated with cited deficiencies.

Unannounced complaint investigation visit conducted in response to allegations including lack of care resulting in a pressure injury, billing for services not rendered, failure to ensure daily activities and adequate feeding, and failure to provide showers as per care plan.

The investigation found the initial allegations regarding pressure injury, billing, activities, and feeding to be unsubstantiated based on statements and document reviews. However, the allegation that staff failed to provide showers to a resident as required by the care plan was substantiated, with documentation showing lack of showers from 8/16 to 8/31/2024. A deficiency was cited for failure to provide basic services including bathing, posing an immediate risk to the resident's health and personal rights.

Complaint investigation was unannounced and triggered by multiple allegations including pressure injury due to lack of care, improper billing, failure to ensure daily activities and feeding, and failure to provide showers. The shower allegation was substantiated; others were unsubstantiated.

The inspection was an unannounced complaint investigation triggered by allegations that staff were not providing laundry services to a resident and that meals were not served in a timely manner.

The laundry service allegation was unsubstantiated as observations and resident interviews confirmed clean clothing and satisfaction with laundry services. The meal service allegation was substantiated, with evidence that residents waited up to 2 hours for food service, though recent improvements were noted.

The complaint investigation was based on allegations that staff were not providing laundry services and that meals were not served timely. The laundry service allegation was unsubstantiated, while the meal service allegation was substantiated based on resident interviews and administrator statements.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not giving residents showers, not assisting with oral hygiene, and not noticing a resident's change in condition.

The investigation found the allegations regarding showers and oral hygiene to be unsubstantiated due to lack of evidence. However, the allegation that staff failed to notice a resident's change in condition was substantiated, with evidence showing staff did not observe a resident's fever and need for medical attention, posing an immediate health risk.

The complaint investigation was initiated based on allegations received on 07/26/2024. The first two allegations regarding showers and oral hygiene were unsubstantiated due to insufficient evidence. The third allegation regarding failure to notice a resident's change in condition was substantiated based on statements and documentation indicating staff did not observe the resident's fever and need for medical treatment.

An unannounced complaint investigation was conducted following allegations that a resident did not receive timely medical attention and that staff failed to follow infection control practices.

The investigation found no substantiated evidence to support the allegations. The complainant had no direct knowledge and the administrator reported no matching infection cases in the past six months. No citations were issued.

The complaint was unsubstantiated due to lack of direct evidence and unidentified involved parties.

The visit was an unannounced follow-up to investigate two incident reports involving medication errors where residents missed scheduled injections.

The inspection found that on July 22 and 23, 2024, two residents missed scheduled injections due to a nurse not showing up and med techs not notifying management. Additional training was provided to 17 staff members, and no apparent harm occurred to the residents.

The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at the assisted living facility.

The facility was observed to be clean, in good repair, and odor-free with no immediate health, safety, or personal rights violations noted. However, three out of five staff files reviewed did not include first aid training, which was cited as a deficiency.

An unannounced complaint investigation was conducted following a complaint received on 2023-09-26 regarding alleged rude behavior by staff towards a resident during hygiene care.

The investigation found no preponderance of evidence to substantiate the allegation of rude behavior by staff towards the resident. Witnesses were interviewed, and the resident denied the allegation in private, resulting in the complaint being unsubstantiated with no citations issued.

The complaint alleged personal rights violation due to staff speaking rudely to a resident during hygiene care. The allegation was unsubstantiated after investigation.

An unannounced case management visit was conducted to follow up on a substantiated complaint investigation regarding failure to seek timely medical care for a resident resulting in multiple injuries.

The investigation confirmed that staff delayed responding to a resident's call for help and failed to follow facility policy to seek medical treatment after a fall, resulting in serious bodily injury and hospitalization. A civil penalty was issued for the violation.

The visit was complaint-related and substantiated. The complaint involved staff not seeking timely medical care for resident R1 after a fall, resulting in multiple injuries.

The visit was an unannounced case management follow-up on a self-reported SOC341 Report of Suspected Abuse involving a resident observed engaging in inappropriate sexual behavior with two other residents.

The facility implemented additional supervision and increased activities for the residents involved. All families were notified, and appropriate reporting was timely submitted. A recent death report was also followed up with an ongoing police investigation. No deficiencies were cited.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-06-14 regarding staffing adequacy, cleanliness, bathing assistance, medication administration, call response times, and facility repair.

The investigation found some allegations unsubstantiated due to lack of preponderance of evidence, such as staffing adequacy and medication administration. However, other allegations were substantiated, including delayed staff response to resident calls, facility not being in good repair, loose medication on the floor, furniture blocking outdoor passageways, and electrical cords across beds posing immediate safety risks. Civil penalties totaling $750 were issued for repeat and zero tolerance violations.

The complaint investigation was unannounced and conducted by Evaluator David Leibert. Allegations included inadequate staffing, unclean mattresses, lack of bathing assistance, medication administration issues, delayed call response, and facility disrepair. Some allegations were unsubstantiated due to insufficient evidence, while others were substantiated based on statements, documents, photographs, and observations. Civil penalties were issued for repeat and zero tolerance violations.

The inspection was conducted as a Case Management-Incident visit following a death report received by the Community Care Licensing (CCL) regarding a resident who passed away while transitioning to hospice care.

No deficiencies were observed or cited during this Case Management-Incident inspection. The resident's care plan had been updated prior to passing, and all appropriate parties were notified. The resident's private room was empty and belongings retrieved by the responsible party.

The inspection was an unannounced Case Management-Other visit to follow up on an Order of Immediate Exclusion letter issued on April 27, 2023.

The Assistant Executive Director confirmed that the Excluded Staff Member is not working, residing, or has ever worked at the facility. No deficiencies were observed or cited during the inspection.

The inspection was conducted as a Case Management-Incident visit following two incident reports received by the Community Care Licensing (CCL) regarding residents choking on food, one on April 9, 2023, and another on April 13, 2023.

No deficiencies were observed or cited during this Case Management-Incident inspection. The Licensing Program Analyst reviewed relevant documents and conducted an exit interview with the Assistant Administrator.

The visit was complaint-related due to two incident reports of residents choking on food. Resident #2 was unavailable for interview. No substantiation status was explicitly stated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-04-10 regarding staff ignoring residents, not meeting residents' care needs, and not providing toilet paper for residents.

The investigation found the allegations unsubstantiated as there was insufficient evidence to prove or disprove the claims. Observations and interviews showed residents engaged with staff and toilet paper was available in all resident rooms.

Complaint control number 21-AS-20230410131207 involved allegations that facility staff ignored residents, did not meet residents' care needs, and did not provide toilet paper. The findings were unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not administering residents' medication as prescribed and that the facility did not have sufficient staff to meet residents' needs.

The investigation found that medication delivery delays were due to pharmacy issues and proper dispensing was resumed on March 1, 2023. The staff schedule and roster were found to be appropriate and up-to-date. The Licensing Program Analyst could not prove or disprove the allegations, resulting in the complaints being unsubstantiated.

The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove or disprove the allegations that staff were not administering medication as prescribed and that there was insufficient staffing to meet residents' needs.

Unannounced complaint investigation visit conducted in response to allegations received on 2023-02-14 regarding food service, personal rights, and physical plant issues including no heat in room and a leaking kitchen sink.

The investigation included interviews, record reviews, and facility tours. The allegations related to food service, personal rights, and physical plant issues were found to be unsubstantiated due to inconsistent statements and lack of corroborating evidence.

Complaint allegations included food service, personal rights, and physical plant issues such as no heat in resident rooms and a leaking kitchen sink. The Licensing Program Analyst conducted multiple inspections and interviews but could not corroborate the allegations. The findings were unsubstantiated.

The inspection was an unannounced Case Management-Deficiencies visit conducted to evaluate compliance related to resident safety and care.

The inspection found a deficiency related to safety measures for residents with dementia, specifically a resident who eloped from the facility without staff knowledge despite being unable to leave unassisted. A plan of correction was required.

The inspection was an unannounced Plan of Correction (POC) inspection conducted to review the facility's submitted Plan of Correction.

The Plan of Correction submitted was observed to be appropriate at the time of the inspection. No deficiencies were observed or cited during this Plan of Correction inspection.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-30 regarding staff response times to resident calls, staff training adequacy, and after-hours phone line responsiveness.

The investigation substantiated that staff did not respond to resident call pendants in a timely manner, staff training was inadequate for 10 staff members including the former Administrator, and after-hours phone calls were missed and not returned timely. One allegation regarding residents' hygiene needs was unsubstantiated due to inconsistent evidence.

The complaint investigation was substantiated for allegations that staff did not respond timely to resident calls, staff training was inadequate, and after-hours phone calls were missed. The allegation that staff did not ensure residents' hygiene needs were met was unsubstantiated due to inconsistent statements and lack of evidence.

Unannounced complaint investigation visit conducted to investigate allegations regarding inadequate supervision resulting in injury and failure to seek timely medical attention.

The investigation found that although the allegations may be true, there was not a preponderance of evidence to prove them true or untrue. Staff were aware of the resident's fall risk and checked on the resident, who was found injured after a fall. Staff called 911 and remained with the resident until paramedics arrived. The allegations were determined to be unsubstantiated.

The complaint was unsubstantiated based on interviews and document review. Allegations included inadequate supervision and failure to seek timely medical attention. No citations were issued.

The inspection was an unannounced required 1-year annual inspection of the Village at Rancho Solano Assisted Living facility to assess compliance with regulatory standards.

The facility was found to be generally clean and safe with proper maintenance of exits, pathways, and fire extinguishers. However, the elevators were last inspected in 2019 and had expired inspection certificates, posing a potential safety risk. The facility is currently on a Fire Watch plan due to a non-functioning fire alarm system. Staff have received PPE training but have not been recertified for N95 fit testing.

The inspection was an unannounced Case Management - Other visit conducted to evaluate the facility, including a fire safety review of the Memory Care Unit on the second floor.

The Fire Alarm system was completely inoperable, and the fire clearance for the second floor Memory Care Unit was denied. Residents were observed residing in the unit without approved fire clearance, resulting in deficiencies and a civil penalty citation.

The inspection was conducted as a Case Management-Incident visit regarding a medication error reported on November 9, 2022, where a resident was over-medicated on insulin due to a nurse not checking the Medication Assessment Record.

The facility nurse over-medicated a resident on insulin, posing an immediate health, safety, and personal rights risk to residents. Deficiencies were cited under California Code of Regulations Title 22, Division 6, Chapter 8, and the Health and Safety Code.

The visit was triggered by a complaint regarding a medication error. The error was substantiated as the nurse over-medicated a resident on insulin due to not checking the Medication Assessment Record. Responsible party and prescribing physician were notified.

The inspection was an unannounced complaint investigation triggered by an allegation that the licensee did not maintain the facility free from hazard.

The investigation substantiated that a metal plate causing uneven flooring was present on November 7, 2022, which led to a resident falling and sustaining a fracture. The deficiency was corrected by the time of the November 18, 2022 visit, with the metal plate removed and the floor aligned.

The complaint was substantiated. The allegation was that the licensee did not maintain the facility free from hazard, specifically related to uneven flooring caused by a metal plate which resulted in a resident fall and fracture.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was in disrepair, specifically concerning a door.

The investigation found the facility to be clean and all exits unobstructed. The door leading into Memory Care was fixed appropriately and in a timely manner. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility was in disrepair (door). The allegation was found to be unsubstantiated after investigation and interviews with the Administrator and Maintenance Director.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/12/2022 concerning neglect, staff conduct, food service, hygiene, and mask compliance at the facility.

The investigation found the initial allegations of neglect, pushing, falsified reports, inadequate food service, hygiene neglect, and mask non-compliance to be unsubstantiated due to lack of preponderance of evidence. However, a separate complaint regarding unclean resident rooms, failure to provide proper rent increase notice, and inadequate linen changes was substantiated with deficiencies cited.

The complaint investigation was unannounced and conducted by Evaluator David Leibert. Allegations included neglect resulting in fractures, staff pushing resident, falsified incident reports, inadequate food service, hygiene neglect, and mask non-compliance. The initial allegations were unsubstantiated. A separate complaint about cleanliness, rent notice, and linen changes was substantiated with deficiencies cited.

The visit was an unannounced case management inspection conducted to close a complaint investigation and to review related deficiencies observed during the investigation.

The inspection found multiple deficiencies including delayed response to call bell alarms, lack of updated care plans for residents, insufficient staff training and certification, staff not associated with the facility, missing criminal record clearances, and failure to conduct timely resident reappraisals.

The visit was conducted to close a complaint investigation regarding delayed call bell responses and other related deficiencies. The complaint was substantiated with findings of delayed alarm responses and multiple regulatory violations.

The inspection was conducted as a complaint investigation following allegations that staff left residents unattended and did not respond to call bells in a timely manner.

The investigation found that although call bell alarms were not answered timely and there was a period with only one staff on duty, there was insufficient evidence to prove or disprove the allegations. Therefore, the complaint was unsubstantiated and no deficiencies were cited.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. The investigation included multiple visits, interviews, and documentation review. Records showed delayed response times to call bells and a resident left unattended for 49 minutes, but evidence was insufficient to confirm violations.

The visit was an unannounced case management inspection related to an incident report submitted by the facility regarding a medication error that occurred on 08/13/2022.

The facility staff administered the wrong medication to a resident, which was identified as an immediate health and safety risk. The facility contacted the primary care physician and responsible party, and the resident was placed on alert charting with no side effects reported. A civil penalty of $250 was issued for this repeated violation within a 12-month period.

The visit was triggered by a complaint/incident report regarding a medication error. The violation was substantiated, and a civil penalty was issued.

The visit was an unannounced Plan of Correction (POC) follow-up to verify correction of a previously cited deficiency regarding a non-functional door to the Memory Care Program entrance.

The door to the Memory Care Program entrance remained non-functional at the time of the visit. The facility is in the process of repairs and switching to a new security system. A civil penalty of $200 was issued for failure to correct the deficiency.

The inspection visit was conducted as a complaint investigation due to the main entrance door to the Memory Care Unit not functioning, requiring staff and visitors to enter through the dining room entrance.

The main entrance door to the Memory Care Unit had not been functioning properly for at least four months due to electrical problems, posing a potential risk to resident safety. Deficiencies related to maintenance and operation were cited.

The visit was complaint-related, investigating the non-functioning main entrance door to the Memory Care Unit. The deficiency was substantiated as the door was under repair and non-functional for at least four months.

The visit was an unannounced follow-up on an incident report regarding a medication error that occurred on July 12, 2022, at the Village at Rancho Solano Assisted Living.

The inspection found that a staff member administered the wrong dosage of medication to Resident #1, which posed an immediate health and safety risk. Deficiencies were cited under California Code of Regulations Title 22 and the Health and Safety Code.

The visit was triggered by an incident report of a medication error involving Resident #1 on July 12, 2022. The Responsible Party and prescribing doctor were notified. The medication error was substantiated.

The visit was an unannounced Case Management visit to follow up on two special incident reports involving residents and to check on the status of the Change of Administrator.

No deficiencies were cited during this inspection. Follow-up was conducted on two incidents involving residents, including one with self-harm attempts and another involving inappropriate caregiver behavior. The facility is arranging re-evaluation and has removed the implicated caregiver. The Change of Administrator paperwork is pending submission.

Licensing Program Analysts conducted an unannounced Case Management inspection and followed up on the status of the Change of Administrator and a self-reported incident involving missing resident items.

No deficiencies were cited during this inspection. The facility agreed to reimburse a resident for any missing items that could not be located, and a police report was filed regarding the incident.

The visit was an unannounced Case Management review conducted by Licensing Program Analysts to follow up on an incident where a resident eloped from the facility unassisted and to review the current situation regarding a Change of Administrator.

The report found that a resident who was unable to leave the facility unassisted eloped, posing an immediate health and safety risk. Additionally, there were delays and ongoing changes related to the facility's Administrator position.

The visit was an unannounced Case Management - Incident Visit conducted to review incidents involving residents, including an elopement and a complaint about outside medical services.

The investigation found that Resident R1 eloped but was not diagnosed with dementia or wandering behavior and was moved to a higher level of care after reassessment. Resident R2 reported pain and discomfort during outside medical services, which led to a police investigation and changes in service provision. No deficiencies were cited during this visit.

Unannounced complaint investigation visit conducted due to allegations of neglect/lack of care including failure to call emergency services when a resident sustained fractures and failure to follow reporting requirements.

The complaint that staff did not call emergency services when a resident sustained fractures was substantiated, resulting in an immediate civil penalty of $500. The complaint that staff failed to call emergency services when a resident passed away and failed to follow reporting requirements was found to be unsubstantiated.

The complaint investigation was substantiated for neglect/lack of care related to failure to call emergency services after a resident sustained fractures. The complaint regarding failure to call emergency services when a resident passed away and failure to follow reporting requirements was unsubstantiated.

The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the assisted living facility.

The facility had COVID-19 and face mask posters, hand sanitizer available, staff wearing masks, and housekeeping working 7 days a week. However, a deficiency was cited for failure to retain original records or photographic reproductions for a minimum of three years, posing a potential health and safety risk.

The inspection was an unannounced complaint investigation triggered by allegations that staff did not seek timely medical care for a resident and neglect/lack of supervision resulting in the resident sustaining multiple injuries.

The investigation substantiated the allegations that staff failed to seek timely medical care for Resident R1 after a fall and neglected to properly observe and report injuries including bruising and pressure injuries. An immediate civil penalty of $500 was assessed for the violation resulting in resident injury.

The complaint was substantiated based on interviews, medical record reviews, and observations. Staff did not respond timely to a fall incident and failed to call 911 as required. Staff also failed to document and report pressure injuries and bruising on the resident. The preponderance of evidence standard was met.

Unannounced visit/investigation of a complaint received on 2022-01-11 regarding allegations of rough handling of a resident and neglect/lack of supervision resulting in an unwitnessed fall.

The investigation found that the resident had sustained injuries and bruising from multiple falls and has medical conditions putting them at high risk for falls. Facility records showed fall protocols were followed, and no witnesses to rough handling were identified. The allegations were unsubstantiated due to lack of preponderance of evidence.

Complaint was unsubstantiated based on interviews and document review; no citations were issued.

The visit was a case management incident following a self-reported theft of money from a resident's room between 10/02 and 10/04, with an amount between $1000 and $1700 reported stolen.

No citations for deficiencies were issued at this time. The facility held a Town Hall Meeting to caution residents about theft and loss, offered lock boxes for residents, and reviewed the theft and loss policy. Police and Ombudsman were notified.

The visit was a case management incident visit conducted due to a self-injury attempt by a resident (R1) reported by the facility.

The facility reported that resident R1 attempted self-injury and was found with a stocking tied to the neck and the grab bar in the bathroom. Emergency services were contacted and R1 was hospitalized. No deficiencies or citations were issued at this time.

The inspection was an unannounced Case Management - Incident visit to follow up on a self-reported incident involving a resident's fall with injury.

The facility reported the fall incident and subsequent investigation, including contacting emergency services, responsible parties, and authorities. No deficiencies were cited during this inspection.

Unannounced complaint investigation visit conducted in response to allegations that staff did not attend to a resident's pendant call in a timely manner and that the facility did not notify the licensing agency of the resident's incident.

The investigation substantiated the allegations, finding that a resident suffered an unwitnessed fall and staff response to the emergency call was delayed over 30 minutes, which violated the residence care agreement. The facility also failed to report the serious injury incident to the licensing agency in a timely manner. A civil penalty of $250 was issued for a repeat violation within 12 months.

The complaint was substantiated based on statements, documents, and photographs. The resident experienced a delayed emergency response of over 30 minutes and the facility failed to timely report the serious injury fall to the licensing agency.

The inspection was an unannounced case management visit to follow up on current construction in the facility and to address Administrator questions regarding residents.

A few potential hazards were noted and addressed during the inspection. No deficiencies were cited.

The inspection was an unannounced case management visit to follow up on multiple self-reported incident reports submitted to Community Care Licensing, including a resident death, missing money, and a fall with injury.

During the visit, Licensing Program Analyst Lopez reviewed documents and took statements related to the incidents. No deficiencies were cited during this inspection.

The inspection was conducted as an unannounced complaint investigation following allegations received on 07/07/2021 regarding the quality of food and availability of hot water for residents at the facility.

The complaint regarding food quality was unsubstantiated after review of records, witness statements, and food sampling. However, the complaint about insufficient hot water was substantiated, with evidence showing residents experienced lack of hot water during May and June 2021, posing an immediate risk to health and welfare.

Two complaints were investigated: 1) Food quality alleged to be poor and difficult to chew for a resident; this was unsubstantiated. 2) Lack of hot water for residents over an extended period; this was substantiated based on statements, records, and resident council meeting notes.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/22/2021 regarding foul odor, improper food preparation, and untimely food service at the facility.

The investigation found no evidence to substantiate the allegations of foul odor or improper food preparation and untimely food service, resulting in an unsubstantiated finding for those complaints. However, a separate complaint regarding insect infestation, facility disrepair, unlabeled food, and unclean food storage areas was substantiated with observed deficiencies in kitchen cleanliness and food storage practices.

The complaint investigation was unannounced and based on allegations of foul odor, improper food preparation, and untimely food service. The initial allegations were unsubstantiated. A separate complaint about insect infestation, facility disrepair, unlabeled food, and unclean food storage areas was substantiated.

The inspection was conducted as an unannounced complaint investigation visit following complaints received on 07/02/2021 regarding mold, lack of showers, urine odors, a stomach outbreak, insufficient administrator presence, pests, and inadequate incontinence care at the facility.

The investigation found no evidence of mold, urine odors, or lack of showers, and the stomach outbreak was reported and source unknown, resulting in unsubstantiated allegations for those complaints. However, the allegations of pests and inadequate incontinence care were substantiated, with evidence of ongoing rodent problems and residents waiting up to two hours for incontinence assistance.

The complaint investigation was triggered by multiple allegations including mold, lack of showers, urine odors, stomach illness outbreak, insufficient administrator presence, pests, and inadequate incontinence care. The mold, shower, urine odor, stomach illness, and administrator presence allegations were unsubstantiated. The pest and incontinence care allegations were substantiated.

The visit was an unannounced case management inspection to evaluate completed renovations at the facility, specifically the conversion of assisted living apartments to memory care support.

The inspection found that 8 of 26 rooms require additional time to complete but can be secured from resident access. Water temperatures and carbon monoxide detectors were within regulation and working order. The fire sprinkler system was undergoing its annual inspection, and the renovated section was approved for delayed egress and ready for resident use. No citations were issued.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-06-11 regarding residents being locked in the facility and not treated with dignity and respect, as well as facility disrepair.

The allegations that residents were locked in the facility and not treated with dignity and respect were found to be unsubstantiated due to lack of preponderance of evidence. However, the allegation that the facility is in disrepair was substantiated based on observations of dirty kitchen equipment, broken appliances, and other maintenance issues posing immediate risk to residents.

The complaint investigation was triggered by allegations received on 2021-06-11 that residents were locked in the facility and not treated with dignity and respect. These allegations were unsubstantiated. A separate allegation that the facility was in disrepair was substantiated based on site visit observations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-04-14 regarding facility staff not responding to a resident's call for help.

The investigation substantiated that on or about April 13, 2021, a resident called the front desk following a fall but did not receive timely assistance for approximately 20 to 30 minutes. The front desk staff failed to respond promptly, posing an immediate risk to the resident's safety and health. Disciplinary action was taken against the staff involved, and a plan of correction was required.

The complaint alleged that facility staff did not respond to a resident's call for help. The allegation was substantiated based on interviews, document reviews, and witness statements. Another allegation regarding insufficient front desk staffing was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not responding to residents' pendents in a timely manner and that staff were not showering residents.

The allegation regarding delayed response to residents' pendents was substantiated based on call log reviews showing numerous delayed or no responses, posing an immediate health and safety risk. The allegation regarding staff not showering residents was found to be unsubstantiated based on documentation and interviews.

The complaint investigation was substantiated for the allegation that staff were not responding to residents' pendents in a timely manner, with evidence from call logs showing response times of 20-30 minutes 319 times, 30 or more minutes 241 times, and no response 281 times between March 25 and April 14, 2020. The allegation that staff were not showering residents was unsubstantiated.