<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 02/11/2025
Date Signed: 02/11/2025 10:51:48 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
11/07/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241107150613
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: 149DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carol DowelTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff retained a resident that has a prohibited health condition
Staff did not ensure facility was free from pests
Medications not administered as prescribed
Medications not properly stored
Staff are not properly trained to use a hoyer lift
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. This investigation included 5 unannounced site visits; a review of documents and statements from staff and witnesses. It is alleged Resident (R1) has a prohibited health condition. Although R1 has a stage 3 wound, R1 is on Hospice which is allowed by regulation. The facility has had a bed bug infestation first apparent in October of 2024. Facility management and housekeeping staff have followed the CA Dept of Public Health guidelines and have employed professional exterminators on a continuous basis throughout the period bed bugs have been present. This Agency has inspected for rodents on site visits conducted on 11/19/24; 12/03/24; and 01/28/2025 with negative results. An audit conducted on 12/17/2024 indicated medications were properly stored and being administered as prescribed. Initially, a Hoyer lift was obtained for Resident (R2) but was not used by staff at the request of R2's family. In service training on Hoyer lift was scheduled for staff but cancelled when it was determined the lift would not be used. Although the allegations may be true, based on observation, records and statements, there is not a preponderance of evidence to prove or disprove the allegations. Therefore, the complaint is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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
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
11/07/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241107150613

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: 149DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carol DowelTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Reporting Requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. This investigation included 5 unannounced site visits; a review of documents and statements from staff and witnesses. Complainant alleges that facility has not complied with required reporting requirements. A review of incidents and reporting made by the facility indicates that Resident (R3) died on 10/18/2024. Title Twenty-Two regulation (87211) requires the facility to report the death of a resident to Licensing within 7 days. The facility’s Death Report For R3 indicates the Guardian/Conservator was notified but does not indicate the notification was sent to Licensing. A thorough search of this agency’s electronic and hard copy files confirms no death report of R3 on file. Based upon the documents reviewed and observations made, the preponderance of evidence standard has been met. Therefore, the complaint 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.
Report left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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-20241107150613
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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2025
Section Cited
CCR
87211
1
2
3
4
5
6
7
87211 Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.. Death of any resident….Based upon record review and
1
2
3
4
5
6
7
Administration will review the requirements of 87211 and provide in service training to staff responsible for making death reports. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.
8
9
10
11
12
13
14
observation, this requirement not met as evidenced by: Death of R3 was not reported to Licensing by the facility. This poses a potential risk to the welfare of residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3