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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 07/18/2022
Date Signed: 07/18/2022 04:25:43 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
05/03/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20220503171424
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:
07/18/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Mikayla MehleisenTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not seek timely medical care.
Staff are not properly trained.
INVESTIGATION FINDINGS:
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At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation and met with Administrator, Mikayla Mehleisen.

During investigation, LPA reviewed documents, made observations, and conducted interviews with staff and residents.

There is an allegation that Staff did not seek timely medical care. Based on File Review conducted, Resident experienced a skin tear after a fall and was taken to the ER the next day by family. Resident Chart Notes indicated that on the Night shift, resident was observed to have very bloody bandages and their shoes were thrown away due to being very bloody. Based on Resident Interview conducted, resident was bandaged after their fall in the afternoon, and their bandage was not checked on or rewrapped until 11:00PM. Resident stated they are on a blood thinner medication.
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: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
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-20220503171424
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: 07/18/2022
NARRATIVE
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Continued from LIC-9099

Based on Staff interviews conducted, if a resident is experiencing a lot of bleeding, facility is to call 911 and send the resident out to be seen. Review of Facility’s Policy and Procedure Manual stated that facility protocol is to notify emergency medical services by calling 911 when a resident exhibits signs of uncontrolled bleeding. The allegation that Staff did not seek timely medical care is SUBSTANTIATED.

There is an allegation that Staff are not properly trained. Based on Interview with Administrator, staff receive training at the time of hire and then annually. Upon Review of Staff Files, LPA observed the following: of the 5 Staff Files reviewed, only 1 file had a current CPR certificate. This file did not have First Aid training. 2 of 5 Staff Files had expired First Aid and CPR certificates and 2 of 5 Staff Files had no First Aid or CPR certificates. Of the Staff Interviews conducted, 2 of 3 staff members stated they have not had first aid training recently. The allegation that staff are not properly trained is SUBSTANTIATED.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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. Copy of report, LIC-809D, and Plan of Corrections discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
05/03/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20220503171424

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:
07/18/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Mikayla MehleisenTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Staff did not replace resident's light bulb in a timely manner.
INVESTIGATION FINDINGS:
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At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation and met with Administrator, Mikayla Mehleisen.

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

There is an allegation that staff did not replace resident’s light bulb in a timely manner. Review of Facility Maintenance Log shows that there was no maintenance job order placed to fix a light bulb during the month of April and May. Based on Interview with Administrator, maintenance job orders take approximately 1-2 days for lightbulb replacements. The allegation that staff did not replace resident’s light bulb in a timely manner is UNSUBSTANTIATED.

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: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220503171424
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: 07/18/2022
NARRATIVE
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Continued from LIC 9099-A

A finding that the complaint is Unsubstantiated means that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220503171424
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: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2022
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care:(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by: Based on Resident File Review, Facility Document Review, and
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Licensee to review Regulation 87465 Incidental Medical and Dental Care, Facility Policy and Procedure Manual, and circumstances when 911 should be called with all staff. Licensee to submit planned training date(s) to CCL by POC due date, 7/19/2022. Licensee to conduct an Inservice Training for all Staff.
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Interviews conducted, the Licensee did not comply with the above regulation and did not call 911 per protocol after observing the resident experience a lot of bleeding. This poses an immediate health and safety risk to residents in care.
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Inservice Training to include following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 8/1/2022.
Type B
08/01/2022
Section Cited
CCR
87411(c)(1)
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87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
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Licensee to ensure that all staff who assist residents with personal activities of daily living have the required First Aid and CPR Training completed and certificates placed on file. Licensee to send Staff Roster and Proof of Training to CCL by POC due date of 8/1/2022.
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Based on LPA’s observations and Interviews conducted, the Licensee did not comply with the above regulation and did not ensure that all staff that assist residents with personal activities of daily living have completed and documented training. This poses a potential health & 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: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5