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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 04/06/2022
Date Signed: 04/06/2022 01:02:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20220120085712
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: DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Mikayla MuehleisenTIME COMPLETED:
01:12 PM
ALLEGATION(S):
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Facility food service is inadequate.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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At approximately 9:50AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Mikayla Muehleisen.

During investigation, LPAs reviewed documents, made observations and conducted interviews of staff and residents.

Facility food service is inadequate. Complaint alleges multiple issues including but not limited to: facility frequently being out of food items, condiments not being provided when residents eat in their rooms, meals not well-rounded or attractive looking, insufficient dining staff, long wait times, and that tables are not sufficiently cleaned. Additionally, residents are “scolded” for sitting in unassigned seats. Investigation revealed that facility does have assigned seating due to COVID-19 protocols, but that residents may request seats to be changed.
Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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 5
Control Number 21-AS-20220120085712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
VISIT DATE: 04/06/2022
NARRATIVE
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Continued from LIC 9099

Per interviews, three of six residents indicated that they were told by staff that they could not speak to residents at other tables or invite other residents to sit at their table. Per interviews, menu items are changed frequently due to food items being unavailable. Per Administrator, they have started using a third-party food delivery service for items that are not in their weekly food shipment. Based on interviews, there are still food items that run out. Multiple residents indicated that service times are slow and sometimes upwards to 30-45 minutes. Residents are allotted have one hour to eat. If Residents are in the first seating, the next resident has to wait or come back. During 1/10/2022 visit, LPAs conducted a walkthrough of the kitchen and observed the following: uncovered seafood in the refrigerator, and food that was not properly labelled. Condiments and sandwich prep station was observed to have serving utensils left in bins. Some condiments and sandwich items appeared dried out and were not covered.

Facility is in disrepair. Complaint alleges that heater in resident room was not working and outdoor passageways are blocked by bushes and vehicles. LPAs reviewed pictures showing overgrown bushes and multiple vehicles parked over the sidewalk, obstructing the passageway. Further interview determined that the heater issue was resolved however the heater is showing the degrees in Celsius and not Fahrenheit. Interviews with residents revealed that requests for repairs were timely aside from one resident who indicated their bathroom lightbulb had not been changed timely.

Based on the Department's 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20220120085712

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: DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Mikayla MuehleisenTIME COMPLETED:
01:12 PM
ALLEGATION(S):
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Resident's call button is not answered in a timely manner.
Resident is not provided a comfortable temperature.
Facility does not conduct emergency evacuation drills.
INVESTIGATION FINDINGS:
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At approximately 9:50AM, Licensing Program Analysts :LPAs) Willis and Felias arrived unannounced to deliver finding regarding the above complaint allegations and met with Administrator, Mikayla Muehleisen.

During investigation, LPAs reviewed documents, made observations and conducted interviews of staff and residents.

Resident's call button is not answered in a timely manner - complaint alleges that the call button is not answered timely. Three of six residents’ interviewed indicated residents' experienced wait times between 20-40 minutes, however Review of call buttons logs showed that most calls were answered in 10 minutes or under with the exception of a smaller amount being responded to in 15 minutes. Per conversation with Administrator, Mikyala, call bells are to be answered within 15 minutes ideally but there is not a policy stating response times.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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 5
Control Number 21-AS-20220120085712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
VISIT DATE: 04/06/2022
NARRATIVE
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Continued from LIC 9099

Resident is not provided a comfortable temperature - Complaint alleges that facility is not a comfortable temperature but clarifying interview indicated that a resident's heater was repaired timely but was showing Celsius instead of Fahrenheit.

Facility does not conduct emergency evacuation drills - Complaint alleges that facility has not had an evacuation drill in 2 years. Per interviews with residents, they are notified when there is an evacuation drill. Review of facility records show that a Fire Drill was conducted 9/17/2021. Disaster drill was conducted 2/4/2022 which included fire, elevator failure and power failure.

Although the allegations may have happened 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220120085712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be
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Adminstrator agrees to submit a written plan that includes: a designated individual to ensure quality assurance of food. This ensures that food is adequate, good quality, and prepared, stored, and served in a safe and healthful manner. Additionally, plan must also include a way for residents to communicate concerns regarding food by POC due date 4/7/2022.
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 selected, stored, prepared and served in a safe and healthful manner.
This requirement has not been met based on interviews and observations showing that food service is inadequate including: food running out, food not being stored appropriately, and food portions being too small. This poses an immediate health and safety risk to residents.
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Type B
04/11/2022
Section Cited
CCR
87307(d)(6)
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87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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Administrator agrees to submit self-certification that passageways will always be kept cleared at all times by POC due date 4/11/2022.
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This requirement has not been met based on review of pictures showing that bushes were overgrown blocking the sidewalk. This poses a potential health and safety risk to 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5