486803653-12-20-2022-21-AS-CMAZ-CMDN79-20221223091218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:50:23 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
08/25/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220825085024

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: 115	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mikayla Muehleisen		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident's sustained an injuries while care
Staff did not seek medical attention for resident
Staff are not responding to resident's call buttons
Staff are mismanaging resident's medication
Staff are stealing from resident's
Staff left resident's unattended
Staff are not properly assessing resident for change in health

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegations. During the course of this investigation, statements were taken from staff and residents; documents were obtained and reviewed; site visits were made to the facility where operations were observed. The following determinations are made: Call logs which report time for staff responses were no longer available for this investigation; A resident who may have had approximately $40 stolen did not make a report to law enforcement or management; Although there have been residents injured in care, investigation suggests that staff responded appropriately and summoned medical care when needed; This Department found no evidence that residents were not properly assessed, left unattended for lengthy periods of time, or that residents' medications have been mishandled by facility staff. Although the allegations may be true or valid, based upon the interviews with staff and residents as well as document reviews, there is not a preponderance of evidence to prove the allegations. Therefore, they are UNSUBSTANTIATED.
No citations issued. Report left at facility.

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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
08/25/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220825085024

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: 115	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mikayla Muehleisen		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
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9

Staff are not meeting resident's hygiene needs
Staff are not properly trained

INVESTIGATION FINDINGS:

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2
3
4
5
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7
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9
10
11
12
13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegations. During the course of this investigation, statements were taken from staff and residents; documents were obtained and reviewed; site visits were made to the facility where operations were observed. The following determinations are made: Facility records indicate S1 was on shift providing resident care on July 31 and that training records for S1 are insufficient to verify that S1 was provided required training prior to working the shift; Interviewed staff report several incidents where staff observed residents in need of hygiene care, in soiled clothing, in need of bathing and changing and appearing not to have been checked by the prior shift. Based upon the statements and records, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20220825085024

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: 12/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/23/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). *** Based upon statements, this requirement has not been met as evidenced by: Staff report that residents have been left in soiled clothing and in	1 2 3 4 5 6 7	Administration to provide written plan to ensure the timely hygiene assessments of residents in care and the documentation of care provided. Submit to CCL for approval by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	need of bathing and changing for prolonged periods of time. ***This posed an immediate risk to the health and personal rights of residents in care.	8 9 10 11 12 13 14
Type B 01/03/2023 Section Cited CCR 87411(c)	1 2 3 4 5 6 7	Personnel Requirements - General. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. *** Based upon records and statements, this requirement has not been met	1 2 3 4 5 6 7	Administration and Management/training staff will review the training requirements for caregiving staff and Administration will submit documentation of training on subject to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	as evidenced by: Training records for S1 are incomplete prior to S1 assisting residents with personal activities of daily living. ***This posed a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

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