486803653-3-17-2021-21-AS-KMOA-BZFTYX-20210325150929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 03/17/2021
Date Signed: 03/17/2021 03:52:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210112080904

FACILITY NAME:	ROCKVILLE TERRACE SENIOR LIVING		FACILITY NUMBER:	486803653
ADMINISTRATOR:	KINDRED NICHOLE		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS:	DATE:	03/17/2021
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Mikayla Muehleisen		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not seek resident timely medical attention

Resident was given wrong medication

INVESTIGATION FINDINGS:

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At approximately 3:45PM, Licensing Program Analyst (LPA) Chris Arnhold contacted Mikayla Muehleisen to deliver investigation findings for the allegations listed above. This visit is being conducted via telephone due to Covid-19 precautions. LPA reviewed resident documents, medication administration records, centrally stored medication records and interviewed staff. The resident notes indicated the facility was in converstation with familiy and hospice regarding the welfare of resident. Resident was sent to the emergency room when a change in condition was observed. Based on interviews and a record review, the medication given to resident was administered as ordered by physician.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
No citations issued. Original signature on file.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021

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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