486803653-5-18-2021-21-AS-KMOA-C38SXV-20210521141635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 05/18/2021
Date Signed: 05/18/2021 05:16:42 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
11/19/2020 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201119154938

FACILITY NAME:	ROCKVILLE TERRACE SENIOR LIVING		FACILITY NUMBER:	486803653
ADMINISTRATOR:	KINDRED NICHOLE		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS: 106	DATE:	05/18/2021
		UNANNOUNCED	TIME BEGAN:	03:16 PM
MET WITH:	Mikayla Muehleisen		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to meet the needs of the residents

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-20201119154938. Due to the COVID - 19 precautions, LPA was not physically present at the site.

It is alleged facility staff failed to meet the needs of the residents, in that facility failed to provide a healthy environment for the residents and residents are not fed, showered or changed. LPA was unable to receive any additional information from reporting party to identify residents affected. LPA conducted interviews and there were no corroborating statements. It was disclosed by facility staff, residents are provided tray service at no extra charge due to Covid-19 precautions and residents requiring assistance during meals are assisted. 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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (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 2