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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:54:43 PM


Document Has Been Signed on 09/28/2023 12:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:MUEHLEISEN, MIKAYLAFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 119DATE:
09/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Assistant Administrator, Hannah Richardson
Assisted Living Resident Care Coordinator, Josephine Garcia Evans, Administrator, Carol Dowell		TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Assistant Administrator, Hannah Richardson and was granted access into the facility. Assisted Living Resident Care Coordinator, Josephine Garcia Evans was also in attendance. Administrator arrived 1 hour later.

During the Case Management-Other inspection, LPA interviewed the staff member regarding an incident that occurred on September 27, 2023, interviewed an outside agency, interviewed a resident in care and reviewed resident and facility records. LPA learned of no concerns regarding any staff members at the facility.

Exit interview was conducted, and a copy of this report was signed and given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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