486803653-10-4-2023-21-AS-BMOS-CWFPK5-20231009112234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:24:04 AM

Substantiated

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
09/18/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230918161317

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: 126	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator, Hannah Richardson Administrator, Carol Dowell		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not provide proper medication assistance to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Saragi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings. 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, LPA Sarangi reviewed residents Medication Assessment Records, facility records and interviewed staff.

Complaint alleges that Staff do not provide proper medication assistance to resident in care. Based on an observation of the Medication Assessment Record (MAR) that was conducted, LPA learned that during the months of April 2023 there were gaps in the administration of medication for multiple medications which included eye drops for Resident #1 (See LIC 9099D). A former staff member missed the administration of eye drops on April 19-23, 2023, April 27 & 28, 2023 and April 30, 2023. An interview with the Administrator confirmed the missed medication administration for said dates. (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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230918161317

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: 10/04/2023

NARRATIVE

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During a review of incident reports for the month of April 2023, the facility did not report the incident to CCL. (See LIC 809) Furthermore, LPA reviewed a sample of residents Medication Assessment Records (MARS) to ensure that there is no pattern of not administering medication. MARS for the sample of residents reviewed were appropriate with time and dates indicated. LPA educated the Assistant Administrator on the importance of administering medication that is prescribed by a physician.

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 Assistant Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230918161317

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: 10/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/05/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Plan of Correction (POC) shall include self-certification of an LIC 9098 understanding the regulation. In addition, Administrator/Licensee shall provide a plan for future compliance and conduct staff training on administering and documenting medication assessment records.
	8 9 10 11 12 13 14	Based on an observation of the Medication Assessment Record (MAR) that was conducted, LPA learned that during the months of April 2023 there were gaps in the administration of medication for multiple medications which included eye drops for Resident #1. A former staff member missed the administration of eye drops on April 19-23, 2023, April 27 & 28, 2023 and April 30, 2023. An interview with the Administrator confirmed the missed medication administration for said dates. This is an immeidate Health, Safety and Personal Rights risk to the residents in care.	8 9 10 11 12 13 14	POC due date for the Plan for Future Compliance will be on October 5, 2023. Training POC due date on October 11, 2023.
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	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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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