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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 10/07/2021
Date Signed: 10/07/2021 02:35:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:MUEHLEISEN, MIKAYLAFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 113DATE:
10/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Mikayla Muehleisen, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Mikayla Muehleisen, Administrator. The purpose of this case management inspection was to follow up on self reported incident submitted to Community Care Licensing (CCL).

On 9/20/21, R1 had an unwitnessed fall with injury. During visit LPA Lopez requested documents and took statements from Administrator. R1 was evaluated in Emergency Room. Facility reported to responsible party, Care Coordinator, doctor and CCL. R1 was monitored by staff when R1 returned from Emergency Room.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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