486803653-12-3-2024-21-AS-KMOA-DBSNP4-20241209093742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:13:22 AM

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
08/23/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240823135406

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:	12/03/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Carol Dowell		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident care needs not being met
Staff smoking marijuana on the premises
Cleaning supplies accessible to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint and met with *****.Complainant alleges resident care needs not being met, staff smoking marijuana on the premises and cleaning supplies accessible to residents in care. Complainant informed care needs are not being met not limited to hygiene and dental care. The 10-day complaint inspection was conducted on 8/29/2024 by LPA Hansen. Hansen made observations, obtained resident records, and conducted interviews. During the course of the investigation, it was revealed that resident (R1) was admitted to the facility 11/2022 and vacated 6/2024. R1’s current service plan signed on 11/12/2023 indicated that R1 was a level 1 needing minimal assistance with ADLs. Medical assessment obtained dated 7/10/2023 supported care needs and indicated R1 has been doing better with supervision. The Department received photos and a document signed by dentist dated 6/12/2024 indicating poor dental hygiene “might” be the cause for cavities and broken tooth noted. Subsequent interviews with staff, memory care coordinator and complainant on 11/19/2024 revealed information to support initial interviews conducted by Hansen. R1 was known to refuse hygiene care and staff would return at a later time to offer assistance.
Continued on second page....

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: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2024

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-20240823135406

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: 12/03/2024

NARRATIVE

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LPA obtained facilities substance abuse policy and interviews conducted did not support that staff are working under the influence. Memory care director informed there have not been any staff terminated for such behavior. Interviews revealed that toxins are stored outside of the dining area in janitors closest. Although, during inspection on 8/29/2024 LPA Hansen observed cleaning products under kitchen sink. They were removed immediately and stored in locked designated area. Interviews revealed that dining area is closed and not accessible after meals and residents are not left in the area alone. Although, toxins were observed there was staff supervision.

The allegations noted above are found to be 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.

Report Left.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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