486803653-6-2-2022-21-AS-KMOA-CGKMZ3-20220722100227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:47:38 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
05/12/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20220512110949

FACILITY NAME:	ROCKVILLE TERRACE SENIOR LIVING		FACILITY NUMBER:	486803653
ADMINISTRATOR:	MUEHLEISEN, MIKAYLA		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS: 114	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Administrator, Mikayla Mehleisen		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Dishwasher is in disrepair.

INVESTIGATION FINDINGS:

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At approximately 10:00AM, Licensing Program Analysts (LPAs) Felias and Leibert arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Mikayla Muehleisen.

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

There is an allegation that dishwasher is in disrepair. Although the dishwasher is functioning, it is not maintaining the proper water temperature needed to comply with regulation. Hot water temperatures were reviewed and observed to have a substantial number of days where the water temperature was below the required disinfecting temperature of 170 degrees F.

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220512110949

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: 06/02/2022

NARRATIVE

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Based on the staff interviews conducted, review of Dish Machine Temperature Log, and LPAs' observations, the preponderance of evidence standard has been met. Therefore, the above allegation is 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.

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC 9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220512110949

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: 06/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/03/2022 Section Cited CCR 87555(b)(31)(A)	1 2 3 4 5 6 7	87555 General Food Service Requirements: (b) The following food service requirements shall apply: (31) Dishes and utensils shall be disinfected: (A) In facilities using mechanical means, by...maintaining hot water at a minimum temperature of 170 degrees F (77 Degrees C) at the final rinse cycle of dishwashing machines...	1 2 3 4 5 6 7	Licensee to submit signed self-certification stating that facility will take steps to bring dishwashing machine water temperature into compliance with regulation and verify with temperature logs over a one week period by POC date of 6/3/2022. Temperature Logs and Proof of Repair to be submitted to CCL by POC date of 6/20/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observations and interviews, LPAs observed that Dishwasher was not maintaining proper water temperature required by regulation. This poses an immediate health, safety, and personal 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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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