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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:33:12 AM

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
12/26/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241226085057
FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:CAROL DOWELLFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 148DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carol DowellTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are mismanaging resident's medication
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 disposition. Through statements and document reviews it has been determined that R1 was prescribed Tramadol to be dosed 1/2 50 mg tab at bedtime as needed for pain but was administered 50 milligrams on several occasions in December, 2024, including 12/09, 12/15, 12/22; and some doses were given twice a day at times other than bedtime. Facility Administration has acknowledged the errors and has taken steps to retrain staff and place protocols in place to avoid future errors. Based upon the statements and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is 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:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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 3
Control Number 21-AS-20241226085057
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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. *** Based on statements and document reviews, this requirement has not been met as evidenced by: R1 was given wrong dose
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Cleared at time of visit. Administrator has provided extensive retraining for staff and put improved protocols in place.

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of Tramadol on 12/09; 12/15; 12/22/2025. This posed an immediate risk to the health of R1.
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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.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
12/26/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241226085057

FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:CAROL DOWELLFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 148DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carol DowellTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff do not keep accurate medication administration record for resident, (R1)
INVESTIGATION FINDINGS:
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.Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. The Complainant reports that R1’s Tramadol has been tracked on the narcotic medication record but has not been tracked on the Medication Administration Record (MAR). R1’s physician has indicated in writing that R1 can determine R1’s need for PRN medication and, as such, there is no requirement that the dose(s) be recorded on the MAR. Based upon the documents reviewed, the allegation is UNFOUNDED, meaning that it is false and, or, without a reasonable basis. The allegation is DISMISSED.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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 3