486803653-10-22-2024-21-AS-KMOA-DAJLNQ-20241030085441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:36:01 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
10/16/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20241016223345

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: 151	DATE:	10/22/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Carol Dowell		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility has bed bugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced in response to the allegation the facility has bed bugs. LPA met with Executive Director Carol Dowell. Based on a review of records which includes service orders and receipts from Clark Pest Control, interviews with staff and outside agencies the allegation of “facility has bed bugs” is SUBSTANTIATED. Facility reported September 23, 2024 was the first sighting of a bed bug in the facility, it was brought to the attention of staff who reached out to Clark Pest Control the same day. Clark conducted on inspection on September 24th. Residents and responsible parties in the areas impacted were notified via a letter, copy provided to the Department. September 26, 2024 Clark set-up the first heat treatment in two (2) rooms in the facility. On September 27, 2024, Clark returned to treat eight (8) additional rooms, they received a bio-spray treatment to ensure the bedbugs do not spread. On September 27, 2024 Clark did an in-service training with the maintenance and housekeeping supervisors who then trained their teams on what to look for and how to address a bed bug sighting among other topics. Clark Pest Control will be on property October 22, 2024 to conduct a follow-up visit and address any additional areas of
concern.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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 3

Control Number 21-AS-20241016223345

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: 10/22/2024

NARRATIVE

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The Administrator did follow reporting requirements and reported the bed bug situation via a Special Incident Report received on September 23, 2024 along with an email to LPA Hansen with a copy of a letter sent out to those residents impacted by the situation.

During the investigation the Administrator provided the Department a list of preventative measures they are talking moving forward which include; checking rooms and common areas daily, shop vacuuming every other day, looking for new bug activity, picking up trash daily to ensure it is concealed in the dumpsters only, laundry is placed in plastic bags and a separate washing machine is used for any laundry from the rooms identified and treated, laundry is done using the hottest temperatures.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20241016223345

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: 10/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/24/2024 Section Cited CCR 87303	1 2 3 4 5 6 7	87303 Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Based on records and statements, this requirement not met as evidenced by: Facility has presence of bed bugs in multiple rooms in one section of facility.	1 2 3 4 5 6 7	Administrator will continue to work with Clark Pest Control to remedy the situation and ensure there is a long term plan going forward. Facility will ensure all staff (on all shifts), residents and their responsible parties are aware of the bed bug situation and steps to take if they identify a bed
	8 9 10 11 12 13 14	This poses an immediate risk to residents in care.	8 9 10 11 12 13 14	bug in their living unit and/or common areas. Administrator will submit plans to RO by POC date of October 24, 2024 along with copies of communication to all staff, residents and their responsible parties.
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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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

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