486803653-8-9-2021-21-AS-DTOA-C5QRG7-20210809130012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 08/09/2021
Date Signed: 08/09/2021 01:02:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	KINDRED NICHOLE		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS:	DATE:	08/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Mikayla Muehleisen, Administrator		TIME COMPLETED:	01:10 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	Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Mikayla Muehleisen (MM).The facility currently provides care for 105 total residents with 84 residents in Assisted Living unit and 21 residents in the Memory Care unit. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with 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 were found to be last charged on 2/17/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in designated maintenance and storage closets throughout the facility. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water measured between 100.4 and 125.0 degrees F which is not within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. During the tour LPA observed several over the counter medications in resident R1's bedroom located within the Memory Care unit. In addition, LPA also observed a pair of scissors and three razors in R1's bedroom accessible to residents with dementia. Administrator and care staff immediately removed all medications and sharps in R1's bedroom and placed in a secured medication room (photos taken). Infection Control: Facility has submitted a mitigation program plan which has been reviewed during today's visit. The facility is currently above the 70% vaccination rate and residents with no reported or observed symptoms. Unvaccinated staff receive COVID testing once per week. Posters have been placed at the front door, and facility has a station at main entrance with an electronic sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened based on observation or as needed. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 3 out of 6 inspected faucets accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2021
	Plan of Correction
1 2 3 4	Administrator failed to ensure faucets accessible to residents were regulated with hot water measuring within 105 to 120 degrees F. Administrator agrees to coordinate with Maintenance Staff and complete a seven (7) day water temperature log to ensure faucets accessible to residents dispences hot water within Title 22 regulations. The log template is to be submitted to CCL by POC due date 8/10/2021. Completed seven (7) day log to be submitted to CCL on 8/17/2021 along with a signed LIC9098 Proof of Corrections Form.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 4 out of 4 sharps (razor blades & pair of scissors) accessible to residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2021
	Plan of Correction
1 2 3 4	Administrator failed to ensure sharps were kept inaccessible to residents with dementia. Administrator agrees to submit a plan to conduct room checks for all residents in the Memory Care Unit to remove any prohibited items. Administrator to submit plan and LIC9098 to confirm room checks by POC due date 8/10/2021.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA, observation, the licensee did not comply with the section cited above in 4 out of 4 over the counter medications accessible to residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2021
	Plan of Correction
1 2 3 4	Administrator failed to ensure over the counter medication was kept inaccessible to residents with dementia. Administrator agrees to submit a plan to conduct room checks for all residents in the Memory Care Unit to remove any prohibited items. Administrator to submit plan and LIC9098 to confirm room checks by POC due date 8/10/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3