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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920055
Report Date: 01/18/2024
Date Signed: 01/18/2024 11:20:08 AM

Document Has Been Signed on 01/18/2024 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MONTE VISTAFACILITY NUMBER:
045920055
ADMINISTRATOR:WEBSTER, SIMONIEFACILITY TYPE:
735
ADDRESS:1262 14TH STREETTELEPHONE:
(530) 888-5000
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Simonie Webster - administratorTIME COMPLETED:
11:30 AM
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01/18/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with administrators Simonie Webster, Jessie Boothe, and Michelle Frase Chief of Staff and explained the purpose of the visit.

Administrator waived COMP III presentation as they have been operating multiple facilities for several years.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has received fire clearance for six (6) ambulatory clients. The facility has four (4) client bedrooms, one (1) staff room, and three (3) bathrooms. LPA observed a kitchen table and seating for six in the dining room. LPA observed a couch and love seat in the living room and a table and seating for six in the game room.



Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave, and refrigerator were all present and working.

The facility has 1 fully charged fire extinguisher which has been inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. First aid kit is stocked and available for use.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MONTE VISTA
FACILITY NUMBER: 045920055
VISIT DATE: 01/18/2024
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Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. The facility has a linen closet which contains towels and face cloths. Bathrooms were observed to be in good repair.

Storage and lighting are adequate in the home. Medications are to be stored in a locked cabinet in the locked nurses station. Cleaning supplies and toxins are locked up in a cabinet in the laundry room. Also locked in the staff room are knives. Washer and dryer observed in place and ready for use.

There is a locking office space where client and staff files will be stored.

The front yard has a covered porch for the clients to use. The back yard has two patios, multiple shade trees, and a designated smoking area for the clients. There are no pools or bodies of water on the premises.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

Exit Interview and copy of report was provided to the licensee.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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