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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 04:27:48 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
06/06/2022 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20220606102910
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:
01:45 PM
MET WITH:Administrator, Mikayla MehleisenTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility is not following COVID protocols
Facility is not providing adequate food service to residents
Facility does not follow emergency disaster plan requirements
INVESTIGATION FINDINGS:
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At approximately 11:00AM, 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.

There is an allegation that Facility is not following COVID protocols. Throughout the course of this investigation, LPA made the following Observations: LPA observed visitors and residents walk into the facility pass the lobby without signing in or being asked the COVID screening questionnaire per protocol. LPA observed staff and residents not wearing a mask in the facility.

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-20220606102910
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

Additionally, Observations conducted by LPA Canela on 6/10/22, showed the following: an individual entered the facility through a back entrance. The individual walked to the front desk and was not asked for their temperature or if they had their vaccination information or negative COVID-19 test. The allegation that Facility is not following COVID Protocols is SUBSTANTIATED.

There is an allegation that Facility does not follow emergency disaster plan requirements. Based on Review of facility documents, Facility does have an Emergency Disaster Plan in place. However, LPA observations on visits dated 7/7/22 and 7/12/22, showed that Emergency Exit plans were not posted in the facility per regulation. The allegation that facility does not follow emergency disaster plan requirements is SUBSTANTIATED. LPA observations conducted during the 7/18/22 visit showed that facility has since posted exit plans in the facility.

There is an allegation that Facility is not providing adequate food service to residents. Based on Interview with Dining Services Director, Facility worked with the food supplier company, Sysco. Dining Services Director stated that there have been multiple times where Sysco has delivered an incomplete order. The incomplete deliveries have resulted in menus needing to be changed at the last minute. For items that were not available or missing from the Sysco delivery, Facility will purchase the missing items by going to local stores or utilizing a third-party grocery application. Dining Services Director stated that facility is switching food suppliers from Sysco to US Foods. Based on Interview with Administrator, they have not received recent reports about having low quantities of food and have not been needing to use third-party grocery application as often. Administrator stated that Dining Services Director does routine checks and logs what items are low in quantity. Based on Review of Store Receipts, Facility has been purchasing missing items such as fruit, starches, and coffee creamer. Based on LPA’s observations, Facility’s Lunch Menu matches what facility is serving residents for 7/18/22. Additionally, Observations conducted by LPA Canela on 6/10/22, showed the following: 16 pieces of cooked chicken on a cold tray and leftover potatoes and vegetables in a plastic container. The tray and plastic container were not covered. Based on these findings, the allegation that Facility is not providing adequate food service to residents is SUBSTANTIATED

Continued on LIC-9099C

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
Control Number 21-AS-20220606102910
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-9099C

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.



***An immediate civil penalty in the amount of $250.00 has been issued for a repeat violation of
the California Code of Regulations (CCRs) Section 87555(a). The civil penalty will continue to accrue
$100 per day per violation until the violation is corrected.

Exit interview conducted. Copy of report, LIC-809D, LIC-421FC, LIC9102, 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: 3 of 5
Control Number 21-AS-20220606102910
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
87555(a)
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87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Licensee to provide In-service Training regarding Food Service Operations and the importance of properly preparing, storing and serving food. Inservice training to include the following information:
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 This requirement is not met as evidenced by: Based on LPA observations and interviews conducted, the Licensee did not comply with the above regulation and did not ensure that food was properly stored. This poses an immediate health and safety risk to the residents in care.
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 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
87212(c)
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87212 Emergency Disaster Plan (c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by: Based on LPA’s observations, the Licensee did not comply with the above regulation and did not ensure that Facility had emergency exit plans/maps posted.
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Licensee to post Emergency Exits/Evacuation Maps throughout facility by POC due date of 8/1/2022.
LPA Observations on 7/18/22 show that facility has posted exit plans/maps at Elevators.
Deficiency cleared during visit.
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This poses a potential health and 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: 4 of 5
Control Number 21-AS-20220606102910
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 B
08/01/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by: Based on LPA’s observations, the Licensee did not comply with
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Licensee to review COVID Infection Control plan and submit a written plan to CCL on how they will ensure that COVID procedures will be followed. Licensee to provide In-service Training stating that Facility has read and understood COVID procedures based on current Public Health and Social Services Departmental guidelines.
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the Department of Public Health and Department of Social Services Guidelines and Requirements related to COVID-19. LPA observed multiple individuals not wearing a mask and/or not being screened for COVID related symptoms. This poses a potential health and safety risk to residents in care.
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Inservice training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 8/1/2022.


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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: 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)
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