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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202422
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:46:52 PM


Document Has Been Signed on 10/22/2024 01:46 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
SIERRA CASCADE AC/SC, 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:
10/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Esperanza Rodriguez, staffTIME COMPLETED:
11:30 AM
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On 10/22/24, Licensing Program Analyst (LPA) Yang arrived unannounced and attempted to conduct a Case Management Health and Safety check on the residents in care due to the department was notified one of the Licensee is no longer associated with the facility. LPA was greeted and granted entry by staff Esperanza Rodriguez.

All three residents were present upon arrival. During visit, R2 left on outing with resident’s visitor. One staff was observed present. Inside and outside of facility was toured with staff. Based on observation, LPA toured the facility and observed two residents in bedroom. LPA observed adequate nonperishable and perishable food. LPA observed adequate supplies in the detached garage. LPA observed residents’ medication locked in the laundry room.

No deficiency issued.


An exit interview was conducted. A copy of this report was provided to staff, whose signature confirmed receipt of report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
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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