486803653-11-19-2024-21-AS-KMOA-DBNLMD-20241205075232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:13:04 PM

Unsubstantiated

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
10/18/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20241018122417

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: 152	DATE:	11/19/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Carol Dowell		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not prevent a resident from sustaining multiple falls while in care.
Staff are not following resident's care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) arrived unannounced to deliver findings on this complaint. Based upon information obtained during this investigation, which included interviewing staff and outside parties and record reviews, the above allegations are UNSUBSTANTIATED. Interviews and record review revealed resident listed as R1 requires “maximum assistance” with toileting, transfers, mobility, bathing (2x per week), dressing, grooming and medication management. R1 requires “moderate assistance” with coordination of outside agencies and oral hygiene. Service Plan dated 8/11/2024 corroborates the information above and details the assistance required, per Service Plan, R1 is a level 4. An updated Service Plan on record, dated 10/31/2024, shows R1 requires “maximum assistance” with toileting, transfers, mobility, bathing (2x per week), dressing, grooming, medication management and special needs – safety checks 4x per shift and rolling out of bed. R1 requires “moderate assistance” with coordination of outside agencies and oral hygiene. The updated Service Plan indicates R1 is a level 5 and details the assistance required. R1 had recently fallen out of their twin bed numerous times. The updated Service Plan ensures staff on each shift monitor R1 at least 4x per shift. Additionally, interviews with R1’s responsible parties (RP) and copies of correspondence between RP and facility Executive Director show RPs are in the process of obtaining a larger bed for R1

Unsubstantiated

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: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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-20241018122417

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: 11/19/2024

NARRATIVE

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R1 to prevent R1 from rolling off of their bed. Based on interviews with R1, they feel staff are able to meet their needs and respond timely to requests for assistance and call bell. Facility call bell system is not able to pull a log showing calls and response times. An outside party conducting an unrelated visit to R1 pulled the call bell and staff responded within 4 minutes.

Per R1’s Service Plan, R1 is to receive a bath 2x per week. R1 reported that staff assist with bathing and grooming, R1 did indicate refusal to bathe at times, so staff use a sponge bath which R1’s RP assists with obtaining. Outside parties interviewed indicated R1 appears clean and groomed, R1’s bedding and clothing are clean. Outside party interviewed visits R1 2x a week.

Based on information obtained during this investigation, the allegations are UNSUBSTANTIATED meaning although the allegation may have happened or is valid, there is not a preponderance of

evidence to prove the alleged violation(s) did or did not occur. No citations issued this visit.

Report left.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

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