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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 11:30:48 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
03/18/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200318160827
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:
02:30 PM
MET WITH:Nichole KindredTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to provide adequate hygiene maintenance for resident


INVESTIGATION FINDINGS:
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 Licensing Program Analyst Leibert spoke with Administrator Nichole Kindred for the purpose of delivering findings, by phone, due to COVID – 19 precautions. It is alleged that R1 was denied showers for an extended period of time in March of 2020. During the course of the investigation, records were reviewed, including shower logs, statements taken, and communications with the Complaint and facility Administration occurred. The following determinations have been made: R1 was on Hospice in March of 2020. Hospice workers normally provided R1 a shower two times a week and facility staff provide a shower two times a week. For reasons that are not entirely clear, Hospice aides did not visit R1 between 3/8/20 and 4/1/20 and facility staff did not shower R1 in the absence of Hospice. This lack of hygiene maintenance for R1 has been verified by the Facility’s Care Coordinator. Based upon statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is found to be SUBSTANTIATED. 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
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: 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
03/18/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200318160827

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:
02:30 PM
MET WITH:Nichole KindredTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff Neglect resulted in multiple hospitalizations
Staff mismanaged resident’s medications
Staff did not follow doctor’s orders regarding resident’s care.

INVESTIGATION FINDINGS:
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This Department has conducted a complaint investigation regarding the above captioned allegations. Licensing Program Analyst Leibert spoke with Administrator Nichole Kindred for the purpose of delivering findings, by phone, due to COVID – 19 precautions. It is alleged that staff have neglected R1 which has resulted in hospitalizations; failure to notate the administration of medication; and not following the physician’s orders regarding hydration for R1. During the course of the investigation, records were reviewed, which included care notes, fluid intake logs, hospital reports, appraisals and assessments; statements taken, and communications with the Complaint and facility Administration occurred. The following determinations have been made: R1 is over 90 years old and a Hospice patient with memory deficiencies. Facility records suggest that medical attention for R1 was obtained timely. Staff claim that R1 was checked by staff at approximately 4:00am on 3/8/20 prior to R1’s fall that was discovered by staff at approximately 7:00am 3/8/20. Staff admit there was no entry made on 3/1/20 and 3/2/20 on the Medication Administration Record for R1’s medications but also state that the medications were administered but not recorded due to an oversight.
CONTINUED ON SECOND PAGE
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: 2 of 4
Control Number 21-AS-20200318160827
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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Hydration is an issue for R1 and staff assert that R1 was encouraged to intake liquids frequently through out the day. A fluid intake log, was used to track hydration in March of 2020. Prior to March, no log exists. Care notes make periodic reference to encouraging fluid intake for R1. Although the allegations may be true, 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.
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-20200318160827
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 B
11/09/2020
Section Cited
CCR
87464(f)(4)
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87464(f)(4) Basic Services. Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing …. ***This requirement has not been met as evidenced by:
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Administration agrees to provide written plan to CCL by POC date that outlines protocols to be used going forward that will insure the requiremnets of 87464(f)(4) are met for all residents in care.
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Based upon records obtained and statements taken, facility failed to shower R1 between March 18, 2020 and April 1, 2020 despite Resident Appraisal and Physician’s Assessment that indicate assistance with bathing is necessary for R1. This posed a potential risk to the health of the resident 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