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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:27:15 AM


Document Has Been Signed on 10/04/2023 11:27 AM - 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: 126DATE:
10/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator, Hannah Richardson
Administrator, Carol Dowell		TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Farhaan Saragi arrived unannounced at Rockville Terrace Senior Living for the purpose of Case Management-Other inspection. LPA was greeted at the door by, Assistant Administrator, Hannah Richardson, and was granted access into the facility. Administrator arrived 30 minutes later.

During the course of the investigation that was initiated on September 28, 2023, LPA reviewed incident reports for the month of April 2023 and learned that the facility did not report the Missed Medication Administration to CCL (See LIC 9102-Technical Violation). LPA educated the Assistant Administrator on the importance of 87211-Reporting Requirements as it relates to reporting incidents to CCL.

No deficiencies were cited during this Case Management-Other inspection. LIC 9102-Technical Violation was issued to the facility. Exit interview was conducted, and a copy of this report was signed and given to the Assistant Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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