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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 06/15/2020
Date Signed: 06/15/2020 01:55:33 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200129121552
FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:KINDRED NICHOLEFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: DATE:
06/15/2020
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nicole KindredTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff pushed resident in care

Resident sustained unexplained injury
INVESTIGATION FINDINGS:
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At approximately 12:45PM, Licensing Program Analyst (LPA) Chris Arnhold contacted Executive Director Nichole Kindred to deliver findings for this complaint investigation. This visit is being conducted by telephone due to COVID-19 precautions. On 01/31/2020 and 03/10/2020, LPA conducted interviews and reviewed documentation regarding the above allegations. The facility documented multiple incidents where R1 acted aggressivly towards staff, attempting to slap them. Facility notified the physician and responsible party. The investigation could not prove nor disprove that a staff pushed a resident. The staff accused of the incident has documented training and no disciplinary actions on their record. After facility became aware of the allegation they attempted to examine R1 for injuries but R1 refused the assessment. Due to previous incidents where R1 was aggressive towards staff, it is unknown if the unexplained injury was sustained during these acts.
Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20200129121552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
VISIT DATE: 06/15/2020
NARRATIVE
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Continued from LIC9099...
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

No citations issued.

Original Signature on file.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2