Facility Evaluation Report, 10/31/2023 — Solano House, Fairfield CA

On 10/31/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and gathered additional information regarding a client on client (C1 & C2) incident that occurred on 9/16/2023. LPA was greeted by Administrator, Elizabeth Hall. LPA conducted a separate visit on 9/29/2023 to follow up on the incident. LPA toured the facility, interviewed several staff, reviewed records, reviewed facility surveillance footage and made observations. Based on a review of facility surveillance footage, LPA observed the unprovoked assault from client C1 towards client C2. It was found that the incident occurred in the facility dinning area where several other clients were present. C1 was observed to immediately walk into the dining area and proceed towards C2, abruptly leading to C1 striking C2. Behavioral Health Technician (BHT) staff, (S1) was located in the kitchen area with line of sight of client through the kitchen door windows. S1 responded in a timely manner within approximately 12 seconds of the incident initial confrontation.

LPA observed S1 attempting to contact additional BHT staff but due to inconsistencies with the radio walkie system, S1 was unable to successfully contact support. S1 was successfully able to de-escalate the altercation within approximately 11-12 seconds. A second BHT staff (S2) arrived approximately 3 1/2 minutes after the altercation was de-escalated but was not aware the incident occurred. LPA interviewed several staff and based on interviews with staff (S1, S3 & S6) it was consistently found that staff are not properly utilizing the radio system with several staff stating that they've observed other BHT staff either without a radio walkie on their persons or the device being turned off. The facility has implemented a pendant signal system that omits a loud audio signal when activated. During inspection, LPA found that staff S4 did not have either a radio walkie device or pendant signal. S4 additionally admitted that they had removed the pendant signal from their person. LPA and Administrator discussed health & safety risk to clients in care and developed plan of action to remain in compliance moving forward.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.