486803653-9-7-2023-21-AS-KMOA-CVTLXQ-20230919090906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 08/29/2023
Date Signed: 09/07/2023 10:32:25 AM

Unfounded

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
08/03/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230803132825

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: 124	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Carol Dowell, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not assist resident as needed/required.

INVESTIGATION FINDINGS:

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**Amended from original report dated 8/29/2023. Original report was signed by Josephine Garcia-Evans. Amended report dated 9/7/2023 is signed by Administrator, Carol Dowell.** Licensing Program Analyst Leibert (LPA) arrived unannounced to deliver complaint investigation findings. The Department toured the facility, interviewed residents, reviewed resident records and made observations.

Complaint alleges staff did not assist resident (R1) as needed/required regarding services for ambulation and assistance upon medical appointment check-ins. Based upon a review of R1’s resident records including Physician’s Report, Resident Appraisal and Resident Assessment; although R1 is non-ambulatory and utilizing a walker, there is no indication that R1 requires or is to be provided these additional services from the facility with ambulation assistance, transferring or mobility. This agency has investigated the complaint alleging staff did not assist resident as needed/required. We have found that the allegation above is UNFOUNDED, meaning that the allegation is false, and without reasonable basis. No deficiencies cited.

Report left.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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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