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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 03/04/2025
Date Signed: 03/04/2025 01:59:41 PM

Document Has Been Signed on 03/04/2025 01:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR/
DIRECTOR:		CAROL DOWELLFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 199CENSUS: 174DATE:
03/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Robert Coe, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced case management inspection and met with Interim Administrator Robert Coe, The purpose of this case management inspection is to follow up on two self reported incident reports submitted to Community Care LIcensing (CCL) 2/5/2025 & 3/3/2025.

CCL received a self reported incident report reporting on 1/28/2025 resident (R1) was inadvertently administered another residents medication. Primary care physician (PCP) immediately notified along with family and monitored for any negative effects for 24 hours, no adverse side effects noted. Facility conducted in-service with staff and Consonsus pharmacy came out following day and shadowed pass. Facility has hired LVN to oversee medication room/care department.

LPA followed up on a second medication error that occurred on 2/24/2025 when after medication review it was found R2 had been receiving incorrect dosage of medication since start on 2/21/2025. PCP on cite informed along with family. Indicated R2 showed no adverse side effects. Staff training in progress.

This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22 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 with Interim Administrator.
Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2025 01:59 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/04/2025 at 12:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2025
Section Cited

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87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: In review of records, R1 and R2 both had medication error incidents occur.
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Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents. This is an immediate risk to residents health &safety.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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