<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 01/04/2022
Date Signed: 01/04/2022 11:12:33 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
09/28/2021 and conducted by Evaluator Karen Lopez
COMPLAINT CONTROL NUMBER: 21-AS-20210928155104
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: 115DATE:
01/04/2022
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Mikayla Muehleisen, AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not responding to call for service in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/4/22, Licensing Program Analyst (LPA) Lopez arrived at this facility unannounced to deliver findings for the above allegations. LPA met with Administrator, Mikayla Muehleisen outside of facility due to COVID positive staff.
LPA conducted complaint investigation on the allegation regarding staff not responding to call for service in a timely manner. LPA conducted interviews with staff, resident and Administrator. LPA also requested call system logs from facility for all September and October. Administrator stated that facility’s IT department can only retrieve reports for the last 72 hours and anything before that is recycled. LPA received call times for October 5th and October 6th. On 10/19/21 LPA requested call times for all residents and received call times via email. As observed on the call system times, staff did not ensure to attend multiple residents in a timely manner. There were multiple call system chords pulled by residents that took staff 20 minutes to respond. The dates for the call system chords that were pulled and took 20 minutes or more were: 10/17/21 (one resident) 10/19/21 (three resident rooms) 11/5/21 (one resident room).
Continue to LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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
Control Number 21-AS-20210928155104
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: 01/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed two other times that residents pulled call system chords that had a time of 19:19 minutes and 18:47 minutes. During an unannounced complaint visit conducted on 10/19/21, LPA pulled the call system chord in a resident’s room and staff arrived 20 minutes later (photo taken). Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Mikayla Muehleisen and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
09/28/2021 and conducted by Evaluator Karen Lopez
COMPLAINT CONTROL NUMBER: 21-AS-20210928155104

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: 115DATE:
01/04/2022
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Mikayla Muehleisen, AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not assisting resident with care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/4/22, Licensing Program Analyst (LPA) Lopez arrived at this facility unannounced to deliver findings for the above allegation. LPA met with Administrator, Mikayla Muehleisen outside of facility due to COVID positive staff.

It was alleged that staff do not assist resident with care. During complaint investigation, LPA conducted interviews with staff and residents and requested documentation. During interviews with residents on 10/7/21 and 10/19/21, not all residents stated that staff do not assist them with care. During interviews with staff on 10/19/21, staff stated that med techs and caregivers work as a team and help one another when assisting residents. LPA conducted an onsite visit on 10/7/21 and 10/19/21, observations were made of residents in care. LPA observed resident rooms, residents in care and toured facility. LPAs observations on 10/7/21 and 10/19/21 revealed no information to support residents care needs are not being met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20210928155104
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: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2022
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This has not been met as evidence by:
1
2
3
4
5
6
7
Facility will submit proof of staff training to attend residents call system is answered in a timely manner and submit a written plan on how facility will ensure that staff is meeting the residents needs in a timely manner when residents use the call system by 1/11/22.
8
9
10
11
12
13
14
Based on observation and interviews, LPA observed that staff are not assisting residents in a timely manner which poses a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4