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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920055
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:25:40 PM

Document Has Been Signed on 12/15/2023 02:25 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MONTE VISTAFACILITY NUMBER:
045920055
ADMINISTRATOR:WEBSTER, SIMONIEFACILITY TYPE:
735
ADDRESS:1262 14TH STREETTELEPHONE:
(530) 888-5000
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 13CENSUS: 0DATE:
12/15/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Simonie Webster, Administrator
Ifeanyi Ezeany, Applicant
Michelle Frase, Assistant to Applicant		TIME COMPLETED:
02:15 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Simonie Webster, Administrator
Ifeanyi Ezeany, Applicant
Michelle Frase, Assistant to Applicant
Interview Method: Virtual interview (Microsoft Teams)

On December 15, 2023, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB Analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program,
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Note: shows on LIC 809 form capacity of 13, updated to only capacity 6 only. Exit interview conducted with Applicant and Administrator. Report sent via email and informed to return sign copy by end of business day to CAB.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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