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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202422
Report Date: 02/02/2022
Date Signed: 02/02/2022 02:53:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MOUNTAIN VISTA SENIOR CAREFACILITY NUMBER:
157202422
ADMINISTRATOR:HUNT, DANIELFACILITY TYPE:
740
ADDRESS:20001 PIEDRA DRIVETELEPHONE:
(661) 822-3556
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY:6CENSUS: 3DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee Daniel HuntTIME COMPLETED:
11:15 AM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Deborah Greer and discussed the purpose of the visit. Licensee Daniel Hunt met with LPA to assist with the inspection.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed locked in a laundry room. LPA observed the following personal protective equipment in the laundry room; gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks.

Resident’s files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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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