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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:03:43 AM


Document Has Been Signed on 10/21/2022 11:03 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:JEANETTE KINNEYFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 29DATE:
10/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jeannette KinneyTIME COMPLETED:
11:15 AM
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At approximately 8:30AM, 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 10/20/2022. LPA met with Executive Director Jeannette Kinney and reviewed records. The incident report was in regards to an unexpected death of a resident. LPA reviewed resident records and observed resident was seen by paramedics on 10/18/2022, and declined to be transported to the hospital. Based on records reviewed, paramedics did not advise resident they needed to be seen and appeared to look okay. Based on a record review, resident was discharged from the hospital on 10/03/2022 and seen in the emergency room again on 10/08/2022. Resident was observed on 10/19/2022 at breakfast and lunch, sitting in a chair, alert and responsive. Facility staff were conducting rounds at approximately 1:45PM, and found resident in their room, unresponsive. Staff immediately called emergency personnel. Emergency personnel arrived at approximately 2:00PM.
Based on record review and interviews conducted, facility followed proper protocol and regulation.

No citations issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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