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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:23:13 PM


Document Has Been Signed on 06/01/2023 02:23 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:JEANNETTE KINNEYFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 34DATE:
06/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jeannette KinneyTIME COMPLETED:
02:40 PM
NARRATIVE
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At approximately 11:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct the remaining file reviews regarding the required 1 year inspection that was started on 05/08/2023. LPA met with Executive Director Jeannette Kinney. At approximately 12:00PM, LPA reviewed 5 of 35 staff files. 5 of 5 staff records did not contain documentation of current annual training or evidence of initial orientation.
During this visit LPA observed residents in the dinning room waiting for their meals. LPA observed caregivers taking resident food orders at approximately 12:10PM. At approximately 12:40PM, only 9 of 20 residents had received their meal. LPA observed only 1 person in the kitchen preparing the meal. LPA requested copies of planned menus and copies of menus showing what was served for the previous 30 day.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Jeannette Kinney and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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Document Has Been Signed on 06/01/2023 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 236803448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87412(c)

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87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records
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Licensee to submit a written plan to address staff orientation and completion of required annual training and how facility will document. Plan to be submitted to CCL by POC date of 06/23/2023.
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reviewed, Licensee did not ensure staff records contained verification of required staff training. This poses a potential health, safety or personal rights risk to residents in care.
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Type B
06/23/2023
Section Cited
CCR87555(b)(18)

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87555 General Food Service Requirements:(18)Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement is not
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Licensee to submit written plan detailing how facility will ensure sufficient dining room staff are present to ensure resident needs are met. Plan to be submitted to CCL by POC date of 06/23/2023.
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met as evidenced by: Based on observation, facility does not have sufficient food service personnel to meet the needs of residents. This poses a potential health, safety or personal rights risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2