486803653-5-15-2023-21-AS-HDBI-CRVT56-20230516142459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 05/15/2023
Date Signed: 05/15/2023 09:26:56 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
03/22/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230322143424

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: 120	DATE:	05/15/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator, Carol Dowell		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff do not meet residents' incontinence needs and staff do not assist resident with grooming
Staff do not provide resident with bed linen and shower areas are not equipped with shower curtains
Staff do not properly monitor residents for change in condition
Staff do not supply residents with a personal item
Staff do not safeguard residents' personal belongings

INVESTIGATION FINDINGS:

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

During the course of the investigation, LPA Sarangi reviewed resident(s) records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

Complaint alleges that Staff do not meet residents' incontinence needs and staff do not assist resident with grooming. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation.

(Report continued on LIC 9099C)

Unsubstantiated

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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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 6

Control Number 21-AS-20230322143424

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: 05/15/2023

NARRATIVE

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In addition, LPA reviewed resident records and conducted additional interviews, and learned that Resident #1 is incontinent and that the staff work very hard to keep Resident #1 groomed, clean, fed, and safe in placement.

Complaint alleges Staff do not provide resident with bed linen and shower areas are not equipped with shower curtains. Based on observations that were conducted on March 23, 2023, April 4, 2023 and May 15, 2023, LPA observed resident beds being outfitted with mattress bed linens and shower areas were equipped with shower curtains.

Complaint alleges that Staff do not properly monitor residents for change in condition. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation.

Complaint alleges that Staff do not supply residents with a personal item. Based on interviews that were conducted throughout the investigation, LPA learned that the facility doesn’t provide residents with personal item(s) as that is the residents responsibility and/or responsible parties responsibility. In addition, during reviews of the Admission Agreements, LPA observed and learned that it is up to the resident/residents’ responsible parties to ensure that residents are afforded with their own personal item(s).

Complaint alleges that Staff do not safeguard residents' personal belongings. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. Furthermore, during interviews, there were no concerns regarding personal belongings. During observations of the facility on March 23, 2023, April 4, 2023, and May 15, 2023, LPA observed residents with their own personal belongings.

A finding that the complaint allegations of, Staff do not meet residents' incontinence needs and staff do not assist resident with grooming, Staff do not provide resident with bed linen and shower areas are not equipped with shower curtains, Staff do not properly monitor residents for change in condition, Staff do not supply residents with a Personal Item and (Report continued on LIC 9099C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 21-AS-20230322143424

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: 05/15/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Staff do not safeguard residents’ personal belongings are unsubstantiated meaning that although the allegations 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. Exit interview was conducted and a copy of this was report was signed and 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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
03/22/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230322143424

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: 120	DATE:	05/15/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator, Carol Dowell		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff do not maintain facility clean, sanitary and in good repair

INVESTIGATION FINDINGS:

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

During the course of the investigation and during the opening of the complaint, LPA made observations on March 23, 2023 and conducted an interview with the Assistant Administrator.

Complaint alleges that Staff do not maintain facility clean, sanitary and in good repair. During the opening of the complaint on March 23, 2023, LPA conducted a tour with the Assistant Administrator and found Resident #1’s room to be smelling of incontinence and clothes on the bathroom floor (See LIC 812-Observation of Memory Care Unit dated for March 23, 2023).

(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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 21-AS-20230322143424

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: 05/15/2023

NARRATIVE

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Assistant Administrator was present during the tour of Memory Care Unit. Assistant Administrator summoned Housekeeping to the room to clean the room and ensure that the laundry is done (See LIC 9099D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and 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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 21-AS-20230322143424

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: 05/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/22/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Plan of Correction will entail submitting a LIC 9098 indicating that staff understand the regulation. In addition, Administrator shall provide a written summary entailing how this regulation will be met in the future.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on facility observation on March 23, 2023, LPA and Assistant Administrator observed Resident #1’s room to be smelling of incontinence and clothes on the bathroom floor. This is a potential health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14	Plan of Correction due on May 22, 2023.
	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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

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