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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:05:02 PM


Document Has Been Signed on 12/06/2022 12:05 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
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: 26DATE:
12/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jeanette KinneyTIME COMPLETED:
12:15 PM
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At approximately 9:15AM, 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 11/15/2022. LPA met with Executive Director Jeanette Kinney and reviewed records.
On 11/14/2022, Resident 1, (R1) fell in their room while removing hearing aides. R1 complained of hip pain and staff immediately contacted emergency personnel, who transported R1 to the emergency room. R1 was admitted due to fractured pelvis. R1 was receiving Dialysis 3 times a week prior to the fall. Responsible party stopped dialysis on 11/18/2022, R1 declined rapidly and passed on 11/20/2022.

Facility staff responded quickly and followed regulation to ensure the needs of the resident were met.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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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