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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 04/20/2021
Date Signed: 04/27/2021 05:43:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200820101242
FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:KINDRED NICHOLEFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 106DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Mikayla Muehleisen TIME COMPLETED:
03:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide adequate food service to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst A. Canela contacted Administrator, Mikayla Muehleisen for the purpose of delivering finding on the above captioned complaint allegation. The visit was conducted via tele -visit due to the COVID - 19 precautions. LPA was not physically present at the site.
It is alleged staff do not provide adequate food service to residents, more specifically that food is not provided at the same time each day and food is late or not warm. LPA reviewed records and took statements. Staff S1 disclosed to LPA, due to Covid precautions and their dining room being closed, they are providing tray service to all the residents. The dining staff know what the requested item is ahead of time and all meals are prepared and distributed daily to all the residents. They have plenty of staff, so that food can be delivered timely and there may be instances where it may take a couple of minutes more but, nothing major. LPA received statement from reporting party who explained, they had not taken dates and times of when this occurred, but food has not been delivered warm many times. Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. No citations issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200820101242

FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:KINDRED NICHOLEFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 106DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Mikayla Muehleisen TIME COMPLETED:
03:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speaks to resident inappropriately.
Staff are not following resident's dietary needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst A. Canela contacted Administrator, Mikayla Muehleisen for the purpose of delivering finding on the above captioned complaint allegations. The visit was conducted via tele -visit due to the COVID - 19 precautions. LPA was not physically present at the site.
It is alleged previous administrator, S1 spoke to resident R1 inappropriately. S1 denied the allegation. LPA took statement from R1 who stated S1 did not answer her calls and when R1 went to S1 to talk regarding issues at the facility, she was not invited to S1's office. R1 did not disclose S1 Spoke to her harshly or was hollered at, but disclosed she was not able to discuss her concerns as S1 appeared to have no time. It was also alleged staff are not following resident's dietary needs. LPA reviewed R1's physician report and facility resident appraisal and both indicate, R1 did not have any dietary needs. R1 disclosed to LPA she has no concerns with the food being provided and has no dietary restrictions. This agency has investigated the above allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. No citations issued.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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 2