486803653-2-14-2023-21-AS-HDBI-CP5W4M-20230217155745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 02/14/2023
Date Signed: 02/14/2023 01:52:12 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
02/09/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230209115409

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:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator, Mikayla Muehleisen		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not allow family members to visit resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of interviewing the Administrator and delivered complaint findings. LPA was greeted at the front door by Administrator, Mikayla Muehleisen and was granted access into the facility.

During the course of the investigation, LPA reviewed resident records, facility records, Program Plan of Operation, interviewed staff, witnesses and resident in care.

Complaint alleges that Staff did not allow family members to visit resident in care. LPA conducted interviews with staff and a resident. LPA learned throughout the course of the investigation that on January 17, 2023 a visit was barred for one visitor that came to visit a resident. During a subsequent complaint investigation inspection on February 14, 2023, LPA and Administrator reviewed the Visitors Log for said date and no names were reflected on the Visitor Log for the said date. (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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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Control Number 21-AS-20230209115409

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: 02/14/2023

NARRATIVE

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However, the Administrator contacted the Memory Care Director to confirm the said date. LPA and Administrator both confirmed the date (January 17, 2023) of the visitor not being allowed access into the facility with the Memory Care Director. LPA educated the Administrator regarding updating the Program Plan of Operation if visiting time frames have changed (See LIC 9102) and ensuring that visits are being conducted as Per Title 22 regulations (See LIC 9099D).

The following deficiencies were observed (See LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 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 a copy of this report along with appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230209115409

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: 02/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/15/2023 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	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 (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.	1 2 3 4 5 6 7	Licensee/Administrator shall conduct staff training regarding Personal Rights and visitations. Furthermore, Licensee/Administrator shall provide a written statement on how future compliance will be met.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews that were conducted with staff and resident, a visitor was barred from visiting the facility on January 17, 2023 which poses an immeidate health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14	Plan of Correction due on February 15, 2023.
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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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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