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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:13:00 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
06/21/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220621155627
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:
07/26/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Mikayla MuehleisenTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident's room is not maintained clean and sanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings on a complaint that was initiated on June 30, 2022. LPA was greeted at the door by Administrator, Mikayla Muehleisen, and was granted access into the facility.

Complaint alleges that resident's room is not maintained clean and sanitary. During the course of the investigation, LPA toured the facility with the Administrator on July 26, 2022, July 14, 2022 and June 30, 2022. While opening the complaint on June 30, 2022, and during a tour of the facility with the Administrator on this date, LPA observed R1's room having a very strong odor of urine. Furthremore, LPA conducted interviews with a staff member and learned that R1's room was not sanitary.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report along with appeal rights were emailed to the Administrator due to printer issues.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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 2
Control Number 21-AS-20220621155627
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: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited
CCR
87303(a)
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87303(a)-Maitenance and Operation:

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee shall ensure that ALL rooms are kept clean, sanitary and in good condition at ALL times. In addition, LPA requested a summary on how future compliance will be met moving forward.
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This requirement was not met as evidenced by:

Based on observation of the facility with Administrator on June 30, 2022, R1's room had a very strong odor of urine which presents a potential healthy, safety or personal rights risk to the resident in care.
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Plan of Correction due on: August 2, 2022.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2