486803653-4-15-2025-21-AS-BMOS-DFXT8C-20250421143006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 04/15/2025
Date Signed: 04/15/2025 09:22:02 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
02/26/2025 and conducted by Evaluator Shannan Hansen

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250226161300

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:	09:10 AM
MET WITH:	Tedra Godfrey, Regional Operational Specialist		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff do not keep the facility free from bedbugs
Staff do not ensure the facility call system is properly operating

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) Hansen & Deniz arrived unannounced for the purpose of delivering findings on the above complaint allegations. LPA's met with Regional Operational Specialist, Tedra Godgrey. This investigation included 3 unannounced site visits; a review of documents and statements from staff and witnesses.

Complainant alleges staff do not keep the facility free from bedbugs. Complainant indicated they have never been to the facility but were told the facility has been dealing with bedbugs for quite a while and it's in the common areas and common area furniture. The facility has had Clark Pest Control in but has not had any effect or improvements. LPA obtained documents indicating Clark Pest Control conducted treatments for bedbugs on 11/18/2024-12/11/2024-1/7/2025 -1/9/2025 & 1/17/2025 including some with heat. As these treatments did not eradicate the issue, documents obtained, Ecolab Pest Elimination was hired and came out on 2/24/2025 & 2/25/2025 and serviced a few problem resident rooms.
Continue on LIC9099C

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-20250226161300

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

Interviews conducted with staff and residents revealed there have been no bedbugs found in the common areas. Although as a precautionary measure the common areas have been treated for bedbugs as well. There have only been a couple of rooms in AL upstairs that have been the issue. This allegation has been investigation in 2 other complaints 1) 21-AS-20241016223345 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 an 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. 2^nd) 21-AS-20241107150613 - The facility has had a bed bug infestation first apparent in October of 2024. Facility management and housekeeping staff have followed the CA Dept of Public Health guidelines and have employed professional exterminators on a continuous basis throughout the period bed bugs have been present. This Agency has inspected for rodents on site visits conducted on 11/19/24; 12/03/24; and 01/28/2025 with negative results. Unsubstantiated as facility has continued to conduct follow up inspections and treatments – There was not sufficient information obtained to support a violation occurred as facility continues to conduct follow up inspections and treatments. Therefore, allegation staff do not keep facility free of bedbugsis Unsubstantiated

Staff do not ensure the facility call system is properly operating- Complainant alleges the call system (Jeron) doesn't work/does not call to the pagers which has been going on over a year. 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. Complaint #21-AS-20241018122417 investigation revealed in part Facility call bell system is not able to pull a log showing calls and response times. An outside party conducting an unrelated visit to resident (R1) pulled the call bell and staff responded within 4 minutes. Findings were unsubstantiated.

Although the allegation may be true, based upon the review of documents, observations made 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)

Page: 3 of 3

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
02/26/2025 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20250226161300

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:	09:10 AM
MET WITH:	Tedra Godfrey, Regional Operational Specialist		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility does not have a current administrator

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) Hansen & Deniz arrived unannounced for the purpose of delivering findings on the above complaint allegations. LPA's met with Tedra Godfrey, Regional Operational Specialist.
This investigation included 3 unannounced site visits; a review of documents and statements from staff and witnesses.
Facility does not have a current administrator- Complainant alleges there was an administrator on Tuesday (2/25/2025) but was fired on the spot in the building and walked them out. Complaint was submitted on 2/26/2025. Administrator submitted to CCL letter of resignation from position dated 1/31/2025, last day to be 3/1/2025. Documents also obtained & interviews conducted show on 2/26/2025 Carlson Property Management provided Administrator with last check. On 2/27/2025 CCL received notification of new Administrator effective date will be 3/3/2025. Investigation revealed the complaint was opened on 2/26/2025 and as of said date the facility had an active Administrator, per regulations. This agency has investigated the complaint alleging Facility does not have a current administrator.
We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

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)

Page: 2 of 3