<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 08/29/2022
Date Signed: 08/29/2022 04:41:12 PM


Document Has Been Signed on 08/29/2022 04:41 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: 109DATE:
08/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Mikayla MuehleisenTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 2:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case-Management - Plan of Corrections (POC) visit and met with Administrator, Mikayla Muehleisen.

LPA discussed the deficiency cited during a visit conducted on 6/2/2022. Facility had provided Community Care Licensing (CCL) with proof of invoice/repair of dishwasher. Facility provided email updates. During visit, facility provided LPA with temperature log for August 2022 which showed improvement. LPA and Administrator discussed monitoring of temperature and how facility plans on keeping temperature where it needs to be.

LPA discussed the deficiency cited during a visit conducted on 7/18/2022. Facility had provided CCL with In-Service Training discussing COVID Protocol and Procedures. During visit, Administrator provided LPA with a log of frequent visitors with vaccine status. LPA discussed with Administrator the importance of checking negative COVID tests for those who are unvaccinated as stated in PIN 22-07-ASC. Facility plans to ensure compliance by implementing review of COVID tests when needed.

Administrator provided plan of corrections to LPA. Deficiencies cleared during visit.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and POC Letters 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: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1