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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 10/26/2020
Date Signed: 10/27/2020 11:47:56 AM



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
07/27/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200727084510
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:
10/26/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nichole KindredTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident not receiving medication
Resident developed multiple pressure injuries due to lack of staff




INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Administrator Nichole Kindred for the purpose of delivering finding on the above captioned complaint allegations. The visit was conducted via tele -visit due to the COVID - 19 precautions. LPA did not physically present at the site. It is alleged that R1 is not receiving medication from the staff and that R1's pressure injuries are the result of inadequate staff available to turn and reposition R1. The allegations are denied. During the course of the investigation this Department has interviewed staff and witnesses; obtained and reviewed documents. The following determinations have been made: Witnesses have stated that medications have not always been administered at the 0600 hrs time period; the witnesses were not present after 0800hrs; the records suggest the some am medications were administered at 0800hrs. In March of 2017, physician's assessment of R1 notes history of skin condition or breakdown; witness opinions regarding the cause of R1's pressure injuries differ; R1's physician has not responded to this Department's request for opinion regarding the cause of the pressure injuries. Although the allegations may be true, based upon records reviewed and interviews taken, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore the allegations are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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 4
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
07/27/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200727084510

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:
10/26/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nichole KindredTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not able to meet resident's needs due to lack of staff
Staff are not answering residents call lights in a timely manner due to lack of staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Administrator Kindred this date, for the purpose of delivering findings on the above captioned complaint allegations. The visit was conducted via tele - visit due to the COVID -19 precautions. The LPA did not physically present at the site. It is alleged that due to insufficient staffing, R1 did not receive timely 2 hour checks and that staff often do not respond to the call buttons in a timely way. The allegations are denied. This Department has investigated the allegations by obtaining and reviewing records and by conducting interviews. The following determinations have been made: Four witnesses report waiting for response from call buttons for many hours, and one witness reports no response at all. Care plan for R1 notes " 2 hr checks to ensure resident is dry..." Four witnesses state that 2 hour checks for R1 are not occurring with regularity, particularly on the NOC shifts, one witness reporting 6 hours between checks. Witnesses report that staff have reported being overwhelmed due to insufficient staffing as the cause for delay in providing 2 hour checks and for not answering calls for assistance timely. Based upon records reviewed and interviews taken, the preponderance of evidence standard has been met. Therefore, the complaint allegations are SUBSTANTIATED. Continued on second page....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20200727084510
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: 10/26/2020
NARRATIVE
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The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20200727084510
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2020
Section Cited
CCR
87411(a)
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs***Based upon records reviewed and interviews conducted, this requirement has not been met as evidenced by:
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Administration to provide a written plan that outlines protocols going forward that will guarantee that sufficient staff are on duty to ensure that all residents' needs are met timely. Plan to be submitted to CCL by POC date in order to clear the deficiency.
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Witness state that on numerous occasions in the recent past, staff shortages resulted in call buttons not being answered for several hours and 2 hour checks for R1 not occurring timely, sometimes with up to 6 hour delays. This posed an immediate risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4