<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 09/23/2021
Date Signed: 09/24/2021 10:59:04 AM

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 LIVINGFACILITY NUMBER:
486803653
ADMINISTRATOR:MUEHLEISEN, MIKAYLAFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 114DATE:
09/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emily DoranTIME COMPLETED:
11:21 AM
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 Analysts (LPA's) A. Canela and Lopez conducted an unannounced case management inspection and met with Outreach Coordinator/Assistant administrator, Emily Doran. The purpose of this case management inspection is to follow up and obtain additional information on an SOC 341 that was received by outside agency and a self reported incident report that was submitted by the facility to Community Care Licensing (CCL) that occurred on 8/15/2020.

LPAs acquired documentation and reviewed resident R1s records regarding the incident, in which it was reported resident R1 was sent to emergency department on 8/15/2021. It was reported R1 was found on the floor of her bathroom (unwitnessed fall). R1 claimed she was pushed onto the floor by a staff. Facility administrator was not in the facility and LPAs were not able to confirm if an internal investigation was conducted.

LPAs reviewed residents file in which it was documented resident transitioned into their memory care unit from the assisted living unit after R1 was noted to have more anxiety, and agitation. LPAs will review additional information that was requested from facility.

LPAs consulted with facility regarding Covid-19 infection control protocols and went over Provider Informational Notice (PIN) 21-41-ASC.

No deficiencies cited during todays visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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 1