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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:57:07 PM


Document Has Been Signed on 07/07/2022 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:MUEHLEISEN, MIKAYLAFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 115DATE:
07/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Mikayla MehleisenTIME COMPLETED:
03:00 PM
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At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case-Management - Incident visit, and met with Administrator, Mikayla Mehleisen. The purpose of the visit was to follow up on a self-reported incident submitted to Community Care Licensing (CCL).

LPA spoke with Administrator regarding an incident report that was received by CCL on 6/13/2022. Incident report stated that Resident 1 (R1) reported to family that a caregiver exposed themselves to R1. Facility conducted investigation and determined that available facility caregivers, residents, and visitors do not fit caregiver description. Facility is having two employees attend to R1 care needs. Per R1's family, camera in R1's apartment did not note anything on recordings. Facility made all appropriate notifications per regulation.

LPA and Administrator discussed the rules regarding cameras in resident rooms. Facility will have to submit a waiver and/or exception, and Facility Plan of Operations and Facility Admission Agreement will have to be updated. LPA provided Administrator with Resource: Guidelines for Video Surveillance.

No Deficiencies Cited during visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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