486803653-8-8-2023-21-AS-DTOA-CUHVD8-20230808162017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:20:20 PM

Document Has Been Signed on 08/08/2023 04:20 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 LIVING		FACILITY NUMBER:	486803653
ADMINISTRATOR:	MUEHLEISEN, MIKAYLA		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS: 155	DATE:	08/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Carol Dowell, Administrator		TIME COMPLETED:	03:30 PM

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	On 8/8/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Care Coordinator, Josephine Garcia-Evans. Administrator, Carol Dowell was contacted and arrived later in the visit. The facility is a two story building licensed for 169 non-ambulatory and 30 bedridden residents, along with a hospice waiver capacity of 20. The facility currently provides care for 155 residents, 14 of which are receiving hospice services and a dedicated memory care unit. LPA continued with a tour of the facility with Care Coordinator and Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 2/6/2023 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, and inspected by an outside agency with current certification dated 8/12/2022. Elevators were found to have current inspection certification with an expiration date of 1/11/2024. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food delivered twice per week. Food stored in the kitchen were properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions posted on kitchen walls. Toxins are stored in designated facility storage closets located throughout the facility. During inspection LPA observed a cart left by maintenance staff with a hand saw and chemicals located outside of a storage closet located on the first floor. LPA did not observe any residents within the area as a majority of residents were found to be in the dinning hall. LPA discussed concerns with Lead Staff & Administrator and the items were immediately placed in the secured area. Technical Violation issued. There was a supply of hygiene products and paper products available for residents. All resident’s apartments have lighting & appropriate furnishings. Water was measured at faucets in several residents private bedrooms and measured between 108.1 and 115.3 degrees F which is within regulation. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2023

NARRATIVE

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Medications located in medication rooms in both assisted living and memory care unit were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Medication management staff also conduct full medication record audits once per month. During the tour, residents were observed interacting with staff in common spaces, watching television in their private bedrooms, participating in various activities with Activities Director and mingling in the dinning hall with family and amongst each other. Residents are visited by family frequently and interact with one another in the dinning area, common spaces as well as in resident private apartments. There is an ample amount of outdoor space and seating for residents on the front corridor and center patio for additional leisure. The facility conducts emergency disaster drills on a monthly, quarterly and annual basis all of which focus on various emergency types and include both staff and residents.

LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA also conducted a file review for all residents. Upon review, LPA found residents' (R1 & R2) physician's reports; and residents' (R3 & R4) Needs & Service Plans in need of updating. Administrator agrees to provide copies of updated resident records for plan of correction. Technical Violation issued.

Administrator, Carol Dowell's Administrator Certification 6017308740 is valid through 6/6/2024 .

LPA requested the following documents be sent to CCL by COB 9/8/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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