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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:50:46 AM


Document Has Been Signed on 08/19/2022 11:50 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 35DATE:
08/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angie SmithTIME COMPLETED:
12:00 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility, unannounced, to conduct a case management visit in regards to an incident report submitted to CCL on 08/09/2022. LPA met with Executive Director Angie Smith, toured the facility and reviewed records. The nature of this incident was an unexpected death. LPA reviewed resident records. Resident was not under special observation or 1 on 1 care. Based on a review of records and interview with Director, facility followed resident care plan and regulation in the care of this resident.

During this visit, LPA reviewed the facilities infection control procedures and visitation protocols. LPA discussed the Departments Provider Information Notices (PIN's) with Director. When the facility has a Covid Positive resident or staff, those individuals will isolate. Visitation can still occur in other parts of the building, providing the visitor meets the requirements for an indoor visit.

LPA also discussed the activity program at the facility. LPA was informed there is an Interim Activities Director. LPA strongly encouraged Director to plan and execute activities in the memory care section of the facility.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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