<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 05/18/2021
Date Signed: 05/18/2021 05:20:48 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201006132401
FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:KINDRED NICHOLEFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 106DATE:
05/18/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mikayla Muehleisen TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a fall
Resident's care needs are not being met
Resident's call button does not work.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst A. Canela contacted Administrator, Mikayla Muehleisen for the purpose of delivering finding on the above captioned complaint allegation 21-AS-20201006132401. Due to the COVID - 19 precautions, LPA was not physically present at the site.

It is alleged resident sustained a fall, resident care needs are not being met and resident's call button does not work. LPA conducted interviews, reviewed records and a video clip that was provided by R1's family. LPA confirmed the facility was aware of the video camera in the common area of R1's unit. LPA will adress camera regulation in a separate report. During a confidential interview with staff and R1’s family it was disclosed staff went to R1's apartment unit on the evening of 10/2/2020, and on 10/3/2020 around 12:10 am. Investigation and video clips revealed, R1 appeared to be confused on 10/2, at about 10pm at night. R1 told facility staff, he did not have any breakfast and staff informed him, “it was not breakfast time, it was nighttime, but that he did have his dinner still on his table and he should eat something”. R1 expressed it was cold, staff offered to reheat the mash potatoes, broccoli and fish that had been served earlier at dinner time.
Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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 5
Control Number 21-AS-20201006132401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
VISIT DATE: 05/18/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At about 12:10am on 10/3, staff showed up thinking R1 had pulled his call button in the living room, but R1 was not in the living room, R1 was in his room. Staff commented that there was no way he could have pulled that button. At about 12:23am, R1 disclosed to staff he was shaking really bad; as staff left, they stated to R1, “you might have something else going on”. R1's family also disclosed R1 informed staff he was cold and facility staff expressed to R1 that he had four blankets, it was 75 degrees and his room was warm enough. It was also disclosed by family, R1 was heard crying as staff left his unit. Review of the resident appraisal that was documented by facility, R1 did not need special observation due to confusion or forgetfulness. Facility staff failed to observe, document and meet the needs of the resident when he expressed confusion between day and night and expressed to facility to be cold, shivering while at a warm temperature and using 4 blankets. R1 was later seen at around 8am, when facility staff found R1 on the floor next to his bed and staff stated he had rolled out and were unsure how long R1 was on the floor. Although R1 did sustain a fall, it was reported R1 was not a fall risk and there is no supporting documentation to verify if the fall could have been prevented. Hospice agency and family was said to have been notified of the fall and the resident was sent to the hospital where he was later diagnosed with a UTI.
R1's family disclosed there were several times R1 would be pushing the call button because he needed assistance and no one would answer the call or it would take a long time for response. Investigation revealed, the facility staff were taking up to 32 minutes to respond to R1’s call button and in many instances, it was taking staff up to 20 minutes to respond. A statement from staff also corroborated the call button not working properly or identifying which call button was pressed in the room. R1’s family also disclosed in some occasions, when they were there at the facility, and pushed the call button themselves, no one responded, and the call button was not operational, this was brought up with the facility. Facility staff S1 acknowledged there were times where the response time was way longer than what the facility tries to do and states the call button was operational.

Based upon statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20201006132401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2021
Section Cited
CCR
87411(d)(5)
1
2
3
4
5
6
7
87411(d)(5) Personnel Requirements General-(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.
1
2
3
4
5
6
7
Administrator agrees to submit written plan to address Regulation 87411 to CCL by POC date of COB 5/19/2021
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on LPA record review & interviews conducted, facility did not meet the needs of R1, staff failed to recognize & report early signs of illness- to meet the care needs of R1. This poses an Immediate Health and Safety risk to residents in care.
8
9
10
11
12
13
14
and proof of completion of Staff training (staff signatures), and training material to LPA Canela by 5/31/2021
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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20201006132401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2021
Section Cited
CCR
87303(i)(1)(A)
1
2
3
4
5
6
7
87303(i)(1)(A)Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
A) Operate from each resident's living unit.
1
2
3
4
5
6
7
Administrator to send in Written plan on how Call buttons will be operational in the facility and facilities plan to correct issue immediately when a call alert system is not working properly. Plan for staff training.
8
9
10
11
12
13
14
This requirement was not met, as evidenced by: investigation revealed Resident R1's call button did not work at times. This is a potential Health and Safety risk to residents in care.
8
9
10
11
12
13
14
POC due date 5/26/2021 to LPA Araceli Canela
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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2020 and conducted by Evaluator Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20201006132401

FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:KINDRED NICHOLEFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 106DATE:
05/18/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mikayla Muehleisen TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring the resident is being fed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst A. Canela contacted Administrator, Mikayla Muehleisen for the purpose of delivering finding on the above captioned complaint allegation 21-AS-20201006132401. Due to the COVID - 19 precautions, LPA was not physically present at the site.
LPA conducted interviews and reviewed records. It is alleged facility staff are not ensuring the resident is being fed. R1's family alleged the resident had lost over 80 lbs since he moved in on November 2019. On 9/16/2020, family requested the facility monitor and document on clipboard, R1's food intake; 3 days later they stated nothing was documented. LPA received statements from facility, R1 was able to eat on his own and did not require assistance. R1 was placed on hospice on 6/9/2020 for failure to thrive and weight loss, with plan for diet as tolerated for pleasure. R1's physician report shows the same weight on 8/5/2019 and report of 1/5/2020. Facility resident appraisal of 6/9/2020 also shows R1 did not need help eating and was on mechanical soft chopped food which facility states they were providing. Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. No citations issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5