On-site continuum of care (independent, assisted, memory care)
Accessible location with scenic, quiet surroundings
Social dining environment and opportunities for peer interaction
Responsive maintenance for many repair requests
Occasional exceptional clinical leadership and engaged managers
Cons
Inconsistent staffing levels and caregiver shortages
Delays in pendant-call and emergency-response times
Medication-management inconsistencies including dosing errors
Incontinence-care delays and inconsistent bathing schedules
Variable housekeeping and cleanliness standards across units
Unreliable meal-service continuity and inconsistent food quality
Opaque, two-tier fee structure with frequent reassessments and add-on charges
Administrative instability and frequent management turnover
Property-maintenance and infrastructure delays for major systems
Weak belongings-inventory and personal-item security controls
Insufficient supervision and engagement for some residents with cognitive impairment
Gaps in family communication and follow-through on concerns
Inadequate pet oversight in sensitive care areas
Perceived value concerns relative to cost
Summary of reviews
The Village at Rancho Solano elicits a broad range of experiences: many reviewers praise the setting, apartments, amenities and the social environment, while others cite operational and clinical inconsistencies that materially affect resident experience. Physically the community is frequently described as clean, modern and attractively landscaped, with spacious units (many with balconies and kitchenettes), a restaurant-style dining room, theater and multiple activity spaces. Families note useful services such as weekly laundry, shuttle transportation, concerts and a full activity calendar; the property’s secure access and on-site continuum of care are also positive features for those seeking a single-campus option.
Care and staffing are the most polarizing elements. Numerous accounts highlight caring, compassionate caregivers, engaged med-techs and occasional strong clinical leadership. At the same time, a recurring pattern relates to inconsistent staffing levels that appear to produce slow call-response times, delays attending to toileting/bathing needs, and lapses in routine checks. Several descriptions point to medication-management problems (including dosing errors and mix-ups) and to service gaps such as missed or delayed assistance. These issues are most frequently described in assisted- and memory-care contexts, where resident needs are higher and predictable staffing and protocols are more critical.
Dining receives mixed but specific feedback. Many residents and families praise the menu variety, restaurant-style service, and attentive dining staff; others report inconsistent meal quality, late or cold deliveries, coordination problems during service, and substitutions that did not meet dietary needs. Activity programming is generally extensive on paper — concerts, outings, classes and memory-care programming are offered — but engagement varies: some residents participate actively while others remain isolated, and reviewers note that activity frequency and quality can fluctuate with staff changes.
Facility operations and management show both strengths and vulnerabilities. Maintenance and groundskeeping are frequently commended, though some reviews describe delayed repairs to major systems (air conditioning, hot water) and episodic deferred-maintenance items. Administrative concerns include frequent leadership turnover, unclear fee explanations, two-tier pricing with reassessments and add-on charges for higher levels of care or personal care tasks, and uneven follow-through on family concerns. A subset of reviewers raised serious governance issues such as belongings-management problems and allegations of theft; these comments point to the need for robust inventory and accountability processes.
Notable patterns to weigh when considering placement: (1) the quality of daily life depends heavily on unit-level staffing and the current management team — experiences vary widely across time and between assisted and memory care; (2) while the campus and amenities are a strong selling point, operational weaknesses (staffing, medication controls, housekeeping consistency, and fee transparency) have recurring mention and can materially affect safety and satisfaction; (3) some families report excellent clinical direction and rapid responsiveness from particular staff members, indicating pockets of high-quality care amid broader inconsistency.
Prospective residents and families should conduct a focused tour and intake conversation that asks specific, documentable questions: current staffing ratios by unit and shift; pendant-call response-time metrics; medication administration and reconciliation protocols; details of the fee schedule, reassessment triggers and examples of typical add-on charges; housekeeping and laundry frequency by level of care; policies for personal-item inventory and lost-item reporting; and examples of activity participation rates. Asking to meet the current care director and to see recent survey or inspection results may clarify whether positive reports or operational concerns reflect current practice or past, resolved problems.
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Location
The Village at Rancho Solano is located at 3350 Cherry Hills Ct, Fairfield, CA, 94534.
About The Village at Rancho Solano
The Village at Rancho Solano is a senior living community in Fairfield, California, surrounded by California wine country views, rolling green hills, and pretty landscaping with flowers, mature trees, benches, walking trails, and pergolas. The community always stays open and offers 171 apartments across three floors, with studios, one-bedroom, and two-bedroom layouts that include private bathrooms, kitchenettes or full kitchens, walk-in closets, and some have balconies or patios, and residents get individually controlled air conditioning, basic cable, and Wi-Fi. The community focuses on health, wellness, and friendly living, with both assisted living and memory care services available at all hours, and there's support for people living with Alzheimer's or dementia using individualized care plans and cognitive exercises, plus extra care for aging in place, respite stays, hospice, and rehab services.
Staff gets described as friendly and well-trained, helping with daily needs like bathing, dressing, medication reminders, meal preparation, housekeeping, laundry, and transportation, and some residents use home care aides for companionship and non-medical support. Residents can use wheel-chair accessible showers, grab bars, and private dining rooms, and find pet-friendly apartments for small pets. Meals come from a restaurant-style dining room or private rooms, and team members prepare chef-made, nutritious meals with special menus for people needing low sugar, low sodium, or gluten-free diets, and snacks and room service show up throughout the day, and there's a bistro for coffee or wine with friends.
Indoor spaces include a library, grand dining area, movie theater, game room, piano, meeting room, private event space, organized hobby groups, a resident lounge with fireplaces, and a fitness center with wellness programs, while outdoor areas such as courtyards and patios let people relax or garden. Residents enjoy a packed schedule with activities like bingo, happy hour, devotionals, yard games, outdoor events, religious services for Protestant and Catholic, visits from chaplains, and hobby group outings to places like the Western Railway Museum and Jelly Belly Candy Company, as well as community trips to Benicia State Recreation Area, Scandia Family Center, and Eagle Vines Golf Club.
The Village at Rancho Solano provides on-site physical, occupational, and speech therapies, medication management, support groups, specialized memory care, and activities for engagement, movement, and friendship, with a continued care retirement model so people don't need to move as their health needs change. PegasusSeniorLiving.com connects residents and caregivers to online resources like glossaries and planning guides. The building stands out with inviting entrances, tiered water fountains, a beauty salon, community signage, free parking, complimentary and at-cost transportation, and secure outdoor spaces, while inside, there's cable satellite TV, free high-speed Wi-Fi, furniture choices, fireplaces, a billiards lounge, movie theater, and cafe/bistro for snacks and drinks.
The Village at Rancho Solano works with Meta platforms for online conveniences, offering options like Meta Pay, Meta Store, Meta Quest, Ray-Ban Meta, and Meta AI, plus easy logins with Facebook, Messenger, Instagram, and Threads. The facility earned awards for Best of Senior Living and Best Activities in Senior Living, and is known for a welcoming, joyful environment and quality support. You can visit their website at pegassseniorliving.com/the-village-at-rancho-solano for more details or to see what daily life is like.
Pegasus Senior Living, founded in 2018 and headquartered in Grapevine, Texas, operates approximately 39 communities nationwide. Led by industry veterans with decades of experience, they provide independent living, assisted living, and specialized memory care services. Their signature "Connections" program serves residents with dementia.
People often ask...
The Village at Rancho Solano offers competitive pricing, with rates starting at a cost of $2,610 per month.
The Village at Rancho Solano offers independent living, assisted living, and memory care.
There are 46 photos of The Village at Rancho Solano on Mirador.
Yes, The Village at Rancho Solano allows residents to age in place and adjust their level of care as needed.
The full address for this community is 3350 Cherry Hills Ct, Fairfield, CA 94534.
No, The Village at Rancho Solano does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In California, the Department of Social Services' Community Care Licensing Division licenses residential care facilities for the elderly, conducting inspections and investigating complaints.
Investigated the allegation that residents entered another resident's room and identified a deficiency related to personal rights. The allegation that staff left a resident unattended did not result in a deficiency.
Type BCCR 87468.1(a)(1)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
17 Sept 2026Complaint
17 Sept 2026Complaint
Investigated the allegations and concluded they were unsubstantiated.
17 Sept 2026Complaint
17 Sept 2026Complaint
Investigated the complaint and found no deficiencies cited.
17 Sept 2026Complaint
17 Sept 2026Complaint
Investigated the allegations and found the issues unsubstantiated; odors were observed in some common areas while resident rooms were clean, and visitor access concerns were addressed with supervision, with no deficiencies cited.
27 Aug 2026Complaint
27 Aug 2026Complaint
Found no deficiencies. The review found staff training met required hours and resident care needs were addressed appropriately.
27 Aug 2026Inspection
27 Aug 2026Inspection
Found no deficiencies. The non-compliance review addressed staffing, medications, privacy, elopements, and call bells; no deficiencies were cited.
27 Aug 2026Inspection
27 Aug 2026Inspection
Found no deficiencies after investigating a complaint about toileting assistance.
03 Aug 2026Complaint
03 Aug 2026Complaint
Determined that the allegation was unsubstantiated. No deficiencies cited.
03 Aug 2026Inspection
03 Aug 2026Inspection
Investigated a sexual abuse allegation concerning a maintenance employee; determined that additional investigation is needed to determine the facts and circumstances.
09 Jul 2026Complaint
09 Jul 2026Complaint
Investigated the delayed egress signage allegation and found one memory care door lacked the required KEEP PUSHING sign; signage was later installed and confirmed.
HSC 1569.699(a)(7)(A)Signage on delayed egress door
09 Jul 2026Inspection
09 Jul 2026Inspection
Investigated a complaint about delayed medical care and monitoring. Identified deficiencies in timely medical attention and observation that resulted in a serious bodily injury, and assessed civil penalties.
Type ACCR 87411(a)Personnel Requirements
Type ACCR 87466Observation of the Resident
22 May 2026Inspection
22 May 2026Inspection
Investigated a case involving a resident with wounds labeled unstageable and reviewed a death report. No deficiencies were cited.
07 May 2026Complaint
07 May 2026Complaint
Investigated the allegation that staff isolated a resident due to behavior, and found insufficient evidence to prove or disprove it.
16 Apr 2026Inspection
16 Apr 2026Inspection
Identified a noncompliance related to delayed call bell/pendant response times, with alarms going unanswered for over an hour on several occasions.
Type B1569.269(a)(6)
06 Apr 2026Inspection
06 Apr 2026Inspection
Investigated a death after an unwitnessed fall; gathered documents and interviewed staff; no deficiencies cited.
30 Mar 2026Complaint
30 Mar 2026Complaint
Identified that a move-out notice shorter than 30 days led to continued meal and care charges for the full 30-day period, and that requested invoices and resident records were not promptly provided due to miscommunication.
30 Mar 2026Complaint
30 Mar 2026Complaint
Investigated allegations about food service, pest control, safeguarding a resident’s finances from visitors, and providing records to an authorized party; found no violations.
19 Mar 2026Complaint
19 Mar 2026Complaint
Investigated an eviction notice that lacked specific facts to support the eviction, and noted it did not meet regulatory requirements.
Type B87224(a)(3)
Type B87224(d)
12 Mar 2026Complaint
12 Mar 2026Complaint
Investigated the allegation that a resident's care needs were not met, leading to a toe ulcer that required partial amputation.
Type A87465(a)(2)
12 Mar 2026Complaint
12 Mar 2026Complaint
Investigated the unlawful eviction allegation and found there was not a preponderance of evidence to prove or disprove whether it occurred.
12 Mar 2026Inspection
12 Mar 2026Inspection
Investigated two SOC341 reports describing an altercation between two residents in Memory Care; reviewed care plans and found neither required 1-1 care, with no deficiencies cited.
23 Feb 2026Complaint
23 Feb 2026Complaint
Investigated an allegation that unqualified staff administered injections to residents. Interviews showed non-nursing staff gave injections without hand-over-hand procedures and some were unaware of training, although logs indicated injections training occurred on 12/4/25 and 12/25/25.
Type A87629(b)(1)
19 Feb 2026Inspection
19 Feb 2026Inspection
Observed spoiled food and related quality concerns that could affect residents; a deficiency in food service quality was identified.
Type BCCR87555(b)(8)
03 Feb 2026Complaint
03 Feb 2026Complaint
Investigated a complaint about not seeking timely medical care and delayed response to a call button; found deficiencies related to staffing and monitoring after hospital discharge.
Type A87411(a)
Type A87466
03 Feb 2026Complaint
03 Feb 2026Complaint
Identified that a rate increase was charged without proper notice. Also, basic laundry service for a resident was not provided as agreed, while activities were provided and cleaning was maintained.
Type B87307.3(f)
Type B87307.3
Type B1569.657(a)
18 Dec 2025Complaint
18 Dec 2025Complaint
Investigated the allegation that a resident was barred from receiving visitors. Interviews indicated a temporary visitation restriction for one visitor due to staff disruption, with no clear evidence the restriction persisted.
04 Dec 2025Inspection
04 Dec 2025Inspection
Identified a medication discrepancy where insulin intended for one resident was injected into another, posing immediate health risk. The finding was cited as a deficiency.
Type A87465(a)(4)
04 Dec 2025Complaint
04 Dec 2025Complaint
Investigated the allegation that a resident's care needs were not met. Observations showed regular checks, assistance when required, meals delivered, and a clean room, and there was no clear evidence that the alleged deficits occurred.
04 Dec 2025Complaint
04 Dec 2025Complaint
Investigated allegations that staff neglected a resident during transfers and that staff were not properly trained to use a hoyer lift; found insufficient evidence to prove the allegations.
20 Nov 2025Complaint
20 Nov 2025Complaint
Investigated allegations that staff did not respond promptly to residents' requests for assistance and that staff provided care without adequate training.
Type B87468.2(a)(4)
20 Nov 2025Complaint
20 Nov 2025Complaint
Investigated a pest-related complaint and observed ongoing pest-control visits, traps throughout areas, and screen-door installations.
30 Oct 2025Complaint
30 Oct 2025Complaint
Identified concerns about providing basic hygiene items, delays in replacing a lost key, and slow responses to authorized representatives.
Type B87307(a)(3)(D)
Type B87468.1(a)(9)
09 Oct 2025Complaint
09 Oct 2025Complaint
Investigated a complaint that a resident's checks after a change in condition were not performed as required; found three missed night checks and a 22-hour 40-minute gap.
Type B87466
30 Sept 2025Inspection
30 Sept 2025Inspection
Investigated a self-reported allegation of sexual abuse; no deficiencies were cited.
25 Sept 2025Complaint
25 Sept 2025Complaint
Found that a resident's prescribed medication was given in higher doses than ordered on five occasions, including a full tablet instead of the prescribed 0.5 tablet, violating the order of one dose within 24 hours.
Type A87465(a)(4)
25 Sept 2025Complaint
25 Sept 2025Complaint
Investigated an allegation that staff mishandled a resident's prescribed medication, resulting in missed doses. The rent increase allegation was unfounded.
Type A87465(a)(4)
25 Sept 2025Complaint
25 Sept 2025Complaint
Investigated a report that a resident was verbally abused by staff; found insufficient evidence to prove or disprove the allegation.
25 Sept 2025Complaint
25 Sept 2025Complaint
Investigated allegation that a resident was moved to memory care without consent and access to communication was restricted; records showed the resident signed their own admission and medical assessments indicated capacity, with a power of attorney involved in decisions. There was not enough evidence to prove the allegation.
25 Sept 2025Inspection
25 Sept 2025Inspection
Investigated a death report and found no deficiencies cited.
11 Sept 2025Inspection
11 Sept 2025Inspection
Investigated a self-reported incident involving a resident's death; no deficiencies were cited.
28 Aug 2025Complaint
28 Aug 2025Complaint
Investigated allegations that staff did not timely respond to residents' alerts and that residents were left unattended; no deficiencies were cited.
28 Aug 2025Complaint
28 Aug 2025Complaint
Investigated a complaint about food service at a care site; observed that most foods were labeled and dated, but three unlabeled, uncovered cake slices were noted and a tub of peppers showed mold and was reportedly discarded.
28 Aug 2025Complaint
28 Aug 2025Complaint
Investigated the allegation that the administrator lacked an active certification; records show the certification is currently active through 9/17/2026.
28 Aug 2025Complaint
28 Aug 2025Complaint
Investigated an allegation that staff did not keep areas free of rodents; observations and records showed no evidence of rodent activity.
14 Aug 2025Inspection
14 Aug 2025Inspection
Investigated an incident involving a resident who was sent to the hospital and then transferred to a skilled nursing facility. No deficiencies were cited.
10 Jul 2025Complaint
10 Jul 2025Complaint
Identified concerns about medication management, supervision, training, bed bugs, infection control practices, and admissions assessments.
Type A87465(a)(4)
27 Jun 2025Complaint
27 Jun 2025Complaint
Investigated allegations that staff unlawfully evicted a resident and retaliated against a resident; concluded the allegations were unsubstantiated.
27 Jun 2025Complaint
27 Jun 2025Complaint
Investigated allegations of improper food safety and rodent presence; observed compliant food handling and no evidence of rodents, and findings did not establish violations.
27 Jun 2025Complaint
27 Jun 2025Complaint
Investigated the allegations that staff did not properly assess residents and that food service was inadequate. Evidence did not show a preponderance of evidence to support the allegations.
27 Jun 2025Complaint
27 Jun 2025Complaint
Investigated whether staff prevented residents from coming and going freely and whether visits were limited; found that doors were closed after 5:30 pm and interviews showed no ongoing access problems or widespread restrictions.
29 May 2025Inspection
29 May 2025Inspection
Identified a self-reported medication error where oral antibiotics were dispensed instead of the prescribed topical antibiotic, posing an immediate health risk.
Type A87465(a)(4)
29 May 2025Complaint
29 May 2025Complaint
Investigated the allegation that staff did not follow general food service requirements; interviews and observations showed no violations.
15 May 2025Complaint
15 May 2025Complaint
Investigated allegations that staff did not follow a resident's care plan and that residents' personal rights were not protected. Found no evidence to support violations.
29 Apr 2025Complaint
29 Apr 2025Complaint
Found that the allegation that staff did not respond in writing to the Resident Council concerns was unfounded, that meeting notices were not posted in a central location was unfounded, and the allegation that there was no staff liaison to assist the Resident Council was unsubstantiated.
29 Apr 2025Complaint
29 Apr 2025Complaint
Investigated the allegation that staff did not provide resident medication as needed and found insufficient evidence to prove a violation.
25 Mar 2025Inspection
25 Mar 2025Inspection
Investigated a self-reported incident where a resident expressed thoughts of self-harm; no deficiencies were cited.
19 Mar 2025Inspection
19 Mar 2025Inspection
Identified concerns about staffing levels and competencies, medication discrepancies, privacy via cameras, elopement issues, and call-bell response times.
Type B87411(a)
Type B87465(c)(2)
Type B87468.1(a)(1)
18 Mar 2025Complaint
18 Mar 2025Complaint
Identified a personal rights violation where a resident repeatedly entered another resident's space and bed, compromising the latter's privacy.
Type A87468.1(a)(3)
18 Mar 2025Complaint
18 Mar 2025Complaint
Investigated a complaint alleging failure to properly notify a resident or representative of a rate increase and failure to maintain cleanliness. The evidence did not establish the allegations.
06 Mar 2025Inspection
06 Mar 2025Inspection
Observed that personnel records were not readily available for review and a resident with dementia eloped, raising safety concerns.
Type A87705(b)(2)
Type B87412(g)(1)
06 Mar 2025Complaint
06 Mar 2025Complaint
Investigated the allegation that staff did not follow a physician's orders in a timely manner.
Type A87465(a)(1)
04 Mar 2025Complaint
04 Mar 2025Complaint
Identified missing required postings and reviewed meals timing and special diet issues with no conclusive evidence.
Type B87468(a)
Type B87468(c)
21 Feb 2025Complaint
21 Feb 2025Complaint
Investigated allegations that a resident eloped due to staff issues, and that rate increase notices and incident reporting were not properly followed.
Type A87411(a)
Type B87211(a)
Type B87211(a)(1)
Type B1569.657(a)
20 Feb 2025Inspection
20 Feb 2025Inspection
Identified hot water temperatures exceeding regulation at several resident faucets and cleaning chemicals stored in an accessible laundry area in memory care, creating safety risks.
Type A87303(e)(2)
Type B87705(f)(2)
11 Feb 2025Complaint
11 Feb 2025Complaint
Investigated a complaint alleging staff did not provide adequate assistance to residents. The investigation did not establish the allegation.
13 Jan 2025Complaint
13 Jan 2025Complaint
Investigated allegation that cameras in common areas recorded audio and violated residents' personal rights.
Type A87468.1(a)(1)
10 Dec 2024Inspection
10 Dec 2024Inspection
Observed a report of a possible infection involving a resident after the spouse alerted staff; 911 was called, the resident was taken to a medical facility, and later transferred to skilled nursing.
19 Nov 2024Complaint
19 Nov 2024Complaint
Identified that staff did not respond to residents' calls for assistance in a timely manner.
Type A87411(a)
06 Nov 2024Inspection
06 Nov 2024Inspection
Identified that a resident stated they were raped to management and that local police, the responsible party, and the Ombudsman were notified.
05 Nov 2024Complaint
05 Nov 2024Complaint
Identified mold in a resident's shower and ongoing maintenance concerns. The allegation about tripping hazards was not proven.
Type A87303(a)
05 Nov 2024Inspection
05 Nov 2024Inspection
Investigated a citation issued for a health and safety code violation; the citation was cleared.
Type A1569
05 Nov 2024Complaint
05 Nov 2024Complaint
Investigated the allegation that staff did not meet residents' dietary needs and found no preponderance of evidence to prove or disprove the claim.
29 Oct 2024Complaint
29 Oct 2024Complaint
Investigated a medication-management allegation. Found a dosage error where a resident received a full tablet instead of half and insulin no longer ordered, with the MAR showing an incorrect dosage.
Type A87465(a)(4)
10 Oct 2024Complaint
10 Oct 2024Complaint
Identified that a resident was illegally evicted after hospitalization when not allowed to return for a non-prohibited medical condition.
Type A87224(a)
Type A87224(a)(1)
Type A87224(a)(2)
Type A87224(a)(3)
Type A87224(a)(4)
Type A87224(a)(5)
10 Oct 2024Complaint
10 Oct 2024Complaint
Investigated a complaint alleging that resident care needs weren't met, staff training in Hoyer lift and body mechanics was lacking, and charges were made for services not provided. Found there was not a preponderance of evidence to prove or disprove the allegations.
01 Oct 2024Complaint
01 Oct 2024Complaint
Investigated a complaint about staff care and shower provisions. Documentation showed that a resident did not receive showers from 8/16 to 8/31/2023.
Type A87464(f)(4)
01 Oct 2024Complaint
01 Oct 2024Complaint
Investigated allegations about rate increase notices, incontinent care, and dietary/charge documentation.
Type A1569.6557
Type A1569.657
Type B87555(b)(7)
Type B87211(a)(1)
17 Sept 2024Complaint
17 Sept 2024Complaint
Investigated a complaint about laundry service and a complaint about meals being served too slowly. The evidence did not show a preponderance to prove or disprove the laundry allegation, while a deficiency was identified for food service staffing due to meal wait times.
Type A87555(b)(18)
06 Sept 2024Complaint
06 Sept 2024Complaint
Investigated two complaints about how care was provided. Evidence showed showers were performed according to the care plan, and a resident's change in condition was observed on 4/22/2024, leading to medical treatment.
Type A87455
Type A87466
13 Aug 2024Complaint
13 Aug 2024Complaint
Investigated an allegation that a resident contracted a contagious infection and staff were affected because protocols weren't followed. Found no direct knowledge, no recent matching cases, and insufficient evidence to prove or disprove the claim.
08 Aug 2024Inspection
08 Aug 2024Inspection
Identified that two residents did not receive injections as ordered by the physician on July 23 and 24 because the on-duty nurse did not come to work and management was not informed.
Type A87465(c)(2)
22 Jan 2024Inspection
22 Jan 2024Inspection
Identified a deficiency showing three of five staff records lacked required first aid training.
Type B87411(c)(1)
30 Oct 2023Complaint
30 Oct 2023Complaint
Investigated an allegation that unnamed staff spoke rudely to a resident during hygiene care; interviews and records did not provide enough evidence to prove or disprove the claim. No citations were issued.
26 Oct 2023Inspection
26 Oct 2023Inspection
Investigated a case where a resident fall and delayed medical care led to serious bodily injury and hospitalization; civil penalties were determined.
Type A1569.269(a)(6)
Type A87466
Type A15610.67
Type A1569.49
26 Oct 2023Inspection
26 Oct 2023Inspection
Investigated a case management follow-up on a self-reported abuse allegation involving a resident engaging in inappropriate sexual behavior with two other residents.
22 Aug 2023Complaint
22 Aug 2023Complaint
Identified issues with call response times, safety hazards from obstructed passageways, and medication handling; penalties were issued for violations.
Type A87303(a)
Type A87303(i)(1)(2)
Type A87307(d)(6)
06 Jun 2023Inspection
06 Jun 2023Inspection
Investigated a death report involving a resident; the resident passed away while hospice transition was in process. No deficiencies were observed or cited during the case management incident.
15 May 2023Inspection
15 May 2023Inspection
Confirmed the excluded staff member is not present, employed, or residing at the site.
28 Apr 2023Inspection
28 Apr 2023Inspection
Observed two choking incidents involving residents during lunch and an outing; no deficiencies were noted.
28 Apr 2023Complaint
28 Apr 2023Complaint
Found the allegations about staff ignoring residents and failing to meet care needs, and not providing toilet paper, unsubstantiated after investigation.
11 Apr 2023Complaint
11 Apr 2023Complaint
Investigated a complaint alleging issues with food service, personal rights, and a physical plant problem (no heat in a room and a leaking kitchen sink) and found insufficient evidence to prove or disprove these allegations.
11 Apr 2023Complaint
11 Apr 2023Complaint
Investigated two allegations: medication administration as prescribed and staffing levels; evidence showed medication was delivered and schedules were up-to-date, but the investigation could not prove or disprove the allegations.
04 Apr 2023Inspection
04 Apr 2023Inspection
Identified that a resident eloped from the location without staff knowledge on March 20, 2023.
Type A87705(b)(2)
06 Mar 2023Inspection
06 Mar 2023Inspection
Observed that the plan of correction was reviewed and no deficiencies were identified.
13 Feb 2023Complaint
13 Feb 2023Complaint
Identified delays in responding to residents' call pendants, insufficient staff training, and missed after-hours phone calls.
Type A87411(a)
Type A87468.1(a)(9)
Type B87707(a)(1)
Type B87707(a)(2)
17 Jan 2023Complaint
17 Jan 2023Complaint
Found that staff monitored a resident with fall risk during the night, who later fell and required emergency services. The allegations of inadequate supervision and failure to seek timely medical attention were unsubstantiated.
15 Dec 2022Inspection
15 Dec 2022Inspection
Identified that three elevators had not been inspected since 2019 and a Fire Watch was active due to a non-working alarm system awaiting replacement; noted general safety practices and PPE training status.
Type B87303(a)
21 Nov 2022Inspection
21 Nov 2022Inspection
Found the second floor memory care unit did not have an approved fire clearance because the fire alarm system was inoperable, leaving residents on that floor without approved clearance.
Type A87202(a)(1)
Type A87202(a)(2)
18 Nov 2022Inspection
18 Nov 2022Inspection
Identified that a nurse over-medicated a resident with insulin by not checking the MAR. The incident occurred on November 9, 2022.
Type A87465(a)(5)
18 Nov 2022Complaint
18 Nov 2022Complaint
Identified a hazard due to an uneven floor created by a metal plate, which was linked to a resident's fall.
Type B87303(a)
18 Nov 2022Complaint
18 Nov 2022Complaint
Investigated the allegation that a door was in disrepair; the memory care door was fixed promptly and records showed timely repair, and the finding was unsubstantiated.
25 Oct 2022Complaint
25 Oct 2022Complaint
Identified that a complaint alleging neglect and related issues was unsubstantiated, while a separate complaint alleging a dirty room, lack of advance rent notice, and not providing clean linens was substantiated.
Type A87303(a)
Type B87507(f)
Type B87307(3)(C)
16 Sept 2022Inspection
16 Sept 2022Inspection
Identified several regulatory deficiencies, including missing fingerprint clearances, incomplete staff training and files, outdated care plans and reappraisals, and delays in responding to resident call bells. Civil penalties were issued.
Type A87355
Type B87412
Type B1569.625
Type B1569.618(b)(3)
Type B87463(c)
Type B87467
16 Sept 2022Complaint
16 Sept 2022Complaint
Investigated allegations that staff left residents unattended and did not respond to call bells, and found delays in answering calls along with staffing limitations during early morning hours.
02 Sept 2022Inspection
02 Sept 2022Inspection
Identified an incident where a staff member administered the wrong medication to a resident, resulting in a cited deficiency and a civil penalty.
Type A87465(a)(5)
25 Aug 2022Inspection
25 Aug 2022Inspection
Observed a nonfunctional door at the entrance to the memory care program and a civil penalty was issued for failure to correct the deficiency.
Type A87303(a)
09 Aug 2022Inspection
09 Aug 2022Inspection
Identified a main entrance door to the memory care unit that has not functioned properly for about four months, posing a potential safety risk.
02 Aug 2022Inspection
02 Aug 2022Inspection
Identified a medication dosage error during administration that affected a resident on July 12, 2022.
Type A87465(a)(5)
21 Apr 2022Inspection
21 Apr 2022Inspection
Identified two incidents: a resident attempted self-harm after a family visit and a caregiver made sexual verbal comments toward a resident.
11 Apr 2022Inspection
11 Apr 2022Inspection
Identified an ongoing Change of Administrator and a self-reported incident of missing items; many missing items were found in other apartments in the memory care unit, and a police report was filed.
06 Apr 2022Inspection
06 Apr 2022Inspection
Identified an elopement where a resident unable to be in the community unassisted walked away and later returned; found staffing levels insufficient to consistently supervise residents.
Type A87411(a)
16 Mar 2022Complaint
16 Mar 2022Complaint
Investigated an allegation that staff did not call emergency services after a resident fall in September 2020; findings indicated 911 was not called promptly and reporting requirements were not followed.
Type A87465(g)
Type A87469(c)(2)
Type A87469(c)(3)
Type A87469(c)
16 Mar 2022Inspection
16 Mar 2022Inspection
Observed a case management incident where a resident left the premises and returned; afterward, the resident was reassessed and moved to a higher level of care. No deficiencies were cited during the visit.
25 Feb 2022Inspection
25 Feb 2022Inspection
Identified that original records were not retained for the required three years after termination of service, and a resident file was missing.
Type B87506(e)
24 Feb 2022Complaint
24 Feb 2022Complaint
Identified that staff did not seek timely medical care for a resident after a fall and that neglect/lack of supervision led to multiple injuries.
Type A1569.269(a)(6)
Type A87466
17 Feb 2022Complaint
17 Feb 2022Complaint
Investigated a complaint alleging rough handling and neglect leading to unwitnessed falls; found injuries from falls occurred and staff followed fall protocols, but there wasn't enough evidence to prove or disprove the allegations.
03 Nov 2021Inspection
03 Nov 2021Inspection
Investigated a medication transcription error that led to a resident receiving an incorrect dosage and reviewed related incidents and staff training.
Type A87465
27 Oct 2021Inspection
27 Oct 2021Inspection
Identified a theft of money from a resident's room between October 2 and October 4, involving $1,000 to $1,700; police and the ombudsman's office were notified.
27 Oct 2021Inspection
27 Oct 2021Inspection
Documented a resident's self-injury attempt; emergency responders were contacted and the resident was transported to a hospital.
29 Sept 2021Inspection
29 Sept 2021Inspection
Investigated a resident fall and an allegation that a contractor hit the resident; no deficiencies cited.
23 Sept 2021Complaint
23 Sept 2021Complaint
Identified that staff did not respond to a resident's pendant call in a timely manner and the incident was not reported to licensing promptly.
Type A87208(a)(2)
Type B87211(a)(1)(B)
14 Sept 2021Inspection
14 Sept 2021Inspection
Observed a follow-up visit related to ongoing construction and noted a few potential hazards with actions taken; no deficiencies cited.
10 Sept 2021Inspection
10 Sept 2021Inspection
Investigated the death of a resident, missing money, and a fall with injury; no deficiencies were cited.
23 Aug 2021Complaint
23 Aug 2021Complaint
Investigated complaints of a foul kitchen odor, improper food preparation, and meals not served promptly. Findings included roach/rodent infestations, dirty food storage areas and carts, unlabeled or undated food, and broken equipment.
Type A87555(b)(27)
Type B87555(b)(9)
23 Aug 2021Complaint
23 Aug 2021Complaint
Investigated a complaint about meal quality and a hot water shortage affecting residents. The hot water shortage occurred in May and June 2021.
Type B87303(e)(2)
10 Aug 2021Complaint
10 Aug 2021Complaint
Investigated allegations of mold, urine odors, improper showers, a stomach illness linked to food handling, pests, and inadequate incontinence care. Findings showed no mold or persistent odors, acknowledged ongoing rodent issues and bed bugs/scabies, and noted delays in incontinence assistance for some residents.
Type A87625(b)(3)
Type A87468.1(a)(2)
04 Aug 2021Inspection
04 Aug 2021Inspection
Observed that renovations on the second floor were completed and approved for delayed egress with a fire clearance; water temperatures were within regulation and carbon monoxide detectors in resident rooms were working. Eight of 26 rooms lacked furnishings but supplies were available, and the renovated section was ready for resident use; the fire sprinkler system was undergoing its annual inspection.
29 Jul 2021Complaint
29 Jul 2021Complaint
Investigated allegations that residents were locked in and not treated with dignity, and that the setting was in disrepair; observed maintenance issues in the kitchen and other areas during site visits.
Type A87303(a)
03 May 2021Complaint
03 May 2021Complaint
Investigated a complaint about a front desk not answering a resident's call after a fall; found delayed response and concerns about whether staffing at the front desk was sufficient.
Type A1569.269(a)(6)
03 Nov 2020Complaint
03 Nov 2020Complaint
Investigated a complaint that staff did not respond promptly to residents' call pendants and another alleging residents were not showered; reviewed call button logs and the plan of operation for deficiencies.
Type A87208(a)(2)
27 Apr 2020Complaint
27 Apr 2020Complaint
Determined that complaints of neglect and lack of care due to maggot infestation were unfounded after reviewing records and interviewing staff and witnesses.
22 Apr 2020Complaint
22 Apr 2020Complaint
Determined allegations of staff not feeding a resident, overdosing medication, and handling roughly were unfounded, with evidence showing appropriate care and no misconduct.
26 Feb 2020Inspection
26 Feb 2020Inspection
Identified issues with storage of personal items and potential hazards in the memory care unit during inspection. Kitchen and resident rooms were found to be in compliance.
07 Feb 2020Inspection
07 Feb 2020Inspection
Found no deficiencies in the inspection and observed residents engaged in activities.
06 Dec 2019Inspection
06 Dec 2019Inspection
Verified individual's absence and non-employment at the facility. No deficiencies were found during the inspection.
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