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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 11/17/2021
Date Signed: 11/18/2021 12:08:08 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:
11/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mikayla MuehleisenTIME COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) A. Canela 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) by this facility.

On 11/15/2021 facility reported, resident R2 notified facility of a missing gold wedding band. Facility and R2 reported the incident to law enforcement and a police report was filed. Facility expressed they assisted R2 in search of the missing item and took statements. During this visit LPA spoke with resident R2. LPA will request records and received information from facility to interview staff.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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