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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:09:49 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
06/17/2021 and conducted by Evaluator Katrina Walters
COMPLAINT CONTROL NUMBER: 21-AS-20210617094019
FACILITY NAME:ROCKVILLE TERRACE SENIOR LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:KINDRED NICHOLEFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 104DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mikayla MuehleisenTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility did not provide resident's representative with a copy of the resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Walters met with Mikayla Muehleisen (MH), Administrator on this date for the purpose of opening this complaint and delivering findings on the above captioned complaint allegation. Responsible Person for R1 has requested records from R1’s file at the facility. The request was received by the facility via mail and fax on 5/28/2021. An email confirms that the records request was not fullfilled until 6/3/2021.

Based upon the statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 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 and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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
Control Number 21-AS-20210617094019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ROCKVILLE TERRACE SENIOR LIVING
FACILITY NUMBER: 486803653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2021
Section Cited
CCR
1569.269(a)(21)
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1569.269(a)(21) Residents of residential care facilities for the elderly shall have all of the following rights:… To have prompt access to.. records. Photocopied records shall be promptly provided, not to exceed two
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Facility provided copies of records to R1. Administrator will review H&S Code 1569.269 and will submit proof of review and compliance of record request to CCL by POC date.
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business days.....*** Based on interviews and records reviewed, the licensee did provide records requested by R1’s responsible party on 5/28/21. This poses a potential violation of R1’s personal rights.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2