486803653-4-15-2025-21-AS-BMOS-DFXTAA-20250421143314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 04/15/2025
Date Signed: 04/15/2025 09:06:54 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
01/13/2025 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20250113164020

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: 139	DATE:	04/15/2025
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Tedra Godfrey, Regional Operational Specialist		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Insufficient staffing to meet residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPS's) Shannan Hansen & Ali Deniz arrived unannounced for the purpose of delivering findings on this complaint. LPA's met with Tedra Godfrey, Regional Operational Specialist. And discussed the disposition.

Complainant has alleged that facility has insufficient staffing to meet the resident needs by not responding to request for help in an appropriate amount of time. Incident report received by Community Care Licensing (CCL) on 11/10/2024, occurred on 11/1/2024 in am when Resident (R1) pulled call bell cord and was found on toilet with fecal matter on hands and what appeared to be over ripe banana. When staff tried to help R1 get up from the toilet, R1 became defensive and R1 indicated they were not ready to leave. Staff returned later when R1 pulled cord again, finding R1 had vomit and fecal matter on them. Staff suggested to R1 to contact emergency personal, R1 declined. Staff asked responsible party who was on the cell phone with R1 if they could convince R1 to be seen by EMTs, responsible party indicated they would be there shortly. Complainant did not initially provide a date that staff did not respond in a timely manner and, when pressed, indicated 1/6/2025 & 1/9/2025. Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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-20250113164020

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: 04/15/2025

NARRATIVE

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Continued from LIC9099

Although documents obtained of incident reports for resident (R1) going to the hospital submitted to Community Care Licensing (CCL) do not support R1 went to the hospital on 1/6/2025 or 1/9/2025 or in January 2025 via 911 emergency. LPAs interview with responsible party revealed the two indicate dates referenced were doctors’ checkups, not visits to emergency. On 3/4/2025 while at facility LPA observed and learned facility call bell system JERON, located in the nurses’ station, is older and does not print out a history of calls/when cords or buttons are pushed for help. LPA observed for 30 minutes system alarm going off that indicated room number and location (either bedroom/bathroom, etc) with a loud beeping noise that doesn't stop until staff push a button. Nurses station staff then call on walkie talkie to all staff for the nearest available to respond to resident, a staff then will reply they are handling. LPA observed calls being responded to in an appropriate amount of time. Responsible party also informed incident R1 referenced, occurred on 11/1/2024. Staff schedule indicates on Am shift there were 4 caregivers & 2 Med techs, on PM shift there were 3 caregivers & 1 med tech, & on NOC shift, 2 caregivers & 1 med tech. Investigation revealed there was no information obtained to support a violation occurred. The incident complainant has referenced 11/1/2024 was regarding a complaint that had already been investigated from 11/2024 # 21-AS-20241105153420 found unsubstantiated. Interviews conducted and documents reviewed revealed there was insufficient evidence to substantiate the allegation.

Although the allegation may be true, based upon the review of documents and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC9099 (FAS) - (06/04)

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