486803653-8-2-2022-21-AS-HDBI-CH4TKU-20220808144832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 08/02/2022
Date Signed: 08/02/2022 11:52:59 AM

Unsubstantiated

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
05/27/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220527092840

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: 113	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mikayla Muehleisen		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek timely medical help for resident in care
Staff did not dispense medication per physicians orders
Staff do not respond to residents needs in a timely manner
Facility not providing residents with quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the FDA
Staff rush residents to finish meals in dining room

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Administrator and discussed findings. During the course of the investigation, site visits were made, food sampled and photographed, statements taken and documents reviewed. The following determinations are made: Allegations regarding medication administration and timely medical care pertain to R1 who was admitted in 12/2016 and died in 02/2018; R1 self managed R1's medication; records for that period are no longer available for review. During three unannounced site visits the food being served was nutritious, plentiful and tasty; menus comply with requirements and statements from sample diners suggest general satisfaction with food service. R2 alleges to have been kept waiting for entrance to the facility for 4 hours on 4/9/2021 before staff responded and let R2 in the building and claims staff take over one hour to respond to calls to R2's room for assistance; Historic call logs are not retrievable; recent call response for R2 average is 6:49 minutes; staff on duty 4/9/2021 deny R2 waited more that 20 minutes for response. Although the allegations may be true, based on statements, visits, documents, there is not a preponderance of evidence to prove them valid or not true. Therefore the complaint is UNSUBSTANTIATED. Report left.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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 1