486803653-5-16-2024-21-AS-KMOA-D5QQBM-20240529120144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:13:32 PM

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
02/20/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20240220181337

FACILITY NAME:	ROCKVILLE TERRACE SENIOR LIVING		FACILITY NUMBER:	486803653
ADMINISTRATOR:	CAROL DOWELL		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS: 142	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Administrator, Carol Dowell		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident continence care needs not being met

INVESTIGATION FINDINGS:

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On 5/16/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Carol Dowell. LPA toured the facility, interviewed Administrator and outside parties, reviewed resident medical and facility records and made observations during the course of the investigation.

Complaint alleges resident (R1) continence care needs not being met. Based upon interview with outside Home Health Agency Lead Staff (I1), LPA found that there are multiple documented incidents in which R1 had been observed in soiled continence briefs when received by home health nurse (I2). In addition, R1's physician's report indicates that R1 has a bowel and bladder impairment condition indicating an increased level of supervision for R1's continence care needs which is documented on R1's Service Plan. Allegation, continence care needs not being met is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
Appeal Rights Given

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 4

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
02/20/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20240220181337

FACILITY NAME:	ROCKVILLE TERRACE SENIOR LIVING		FACILITY NUMBER:	486803653
ADMINISTRATOR:	CAROL DOWELL		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS: 142	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Administrator, Carol Dowell		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulting in pressure injury
Personal Rights

INVESTIGATION FINDINGS:

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On 5/16/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Carol Dowell. LPA toured the facility, interviewed Administrator and outside parties, reviewed resident medical and facility records and made observations during the course of the investigation.

Complaint alleges a neglect/lack of supervision resulting in pressure injury to resident (R1). Based upon a review of R1's medical records, a physician's order indicated that R1 had developed a stage 2 wound in the sacral region. Based upon interview with Administrator, it was indicated that in January 2024, R1 had an observed wound on the coccyx region in which the facility reported to R1's primary care provider and placing R1 on home health services starting 1/26/2024. Upon review of R1's physician's orders, it is stated that R1 will be receiving wound care from home health skilled nurse 3 times per week and that the wound was considered a stage 2. LPA found that the facility contacted R1's care provider appropriately addressing R1's observed wounds. Continued onto LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 4

Control Number 21-AS-20240220181337

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: 05/16/2024

NARRATIVE

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In addition, based upon R1's physician's report, there are no indications of R1 requiring continuous bed care or repositioning to prevent wounds based on level of care at the time of wound observations. Due to inconsistent and contradicting information gathered, the allegation is found to be unsubstantiated.

Complaint alleges facility violated the personal rights of resident, R1 due to inappropriate request for hospice placement. Based upon interview with Administrator and outside parties, it was found that inconsistencies of communication between Administrator and outside parties (I3), convoluted determining the diagnosis stage of R1's wound and whether the wound was considered a prohibited health condition; stage 3 or higher. Due to inconsistent information gathered, the allegation is found to be unsubstantiated.

A finding that the complaint allegations, neglect/lack of supervision resulting in pressure injury and personal rights are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20240220181337

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: 05/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2024 Section Cited CCR 87466.2	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (4) To care, supervision, and services that meet their individual needs...This requirement was not met as	1 2 3 4 5 6 7	Administrator to provide in-service training for all caregiving staff to review continence care protocols. Administrator to submit scheduled training date to CCLD by POC date 5/17/2024 and submit completed signed training log to CCLD by POC date 5/31/2024.
	8 9 10 11 12 13 14	Based on resident record review and interviews with outside parties (I1), facility did not provide appropriate supervision and assistance with R1's continence care needs. This serves as an immediate health & safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	Administrator to provide in-service training to review continence care protocols and submit signed training log to CCLD by POC date 5/31/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

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