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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 09/12/2022
Date Signed: 09/12/2022 01:17:36 PM


Document Has Been Signed on 09/12/2022 01:17 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: 110DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marketing Director/Assistant Administrator, Hannah RichardsonTIME COMPLETED:
01:30 PM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Case-Management Other Visit, and met with Marketing Director and Assistant Administrator, Hannah Richardson. Administrator, Mikayla Muehleisen, was unavailable during visit.

The purpose of today's visit is to ensure that the facility is following COVID protocols per state regulation. Upon LPA's arrival, LPA observed a letter of notice, dated for February 8, 2022, explaining guidelines for vaccinated and unvaccinated visitors.

LPA and Assistant Administrator discussed the following:
  • Updating visitor information
  • Discussing with the Receptionists or staff who work at the front desk what they need to do when a visitor arrives
  • Facility can use their supply of antigen tests if needed, for visitors who are unvaccinated and do not have proof of a negative COVID test to provide to facility
  • Having a log to verify that negative antigen tests are being reviewed by Receptionists
  • Emailing Resident contacts to update them on current COVID protocols so they are aware of what to expect when coming to the facility

LPA conducted a walk-through of the facility.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report 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: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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