236803448-8-10-2023-21-AS-BMOS-CUWMGF-20230821093551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 08/10/2023
Date Signed: 08/10/2023 01:17:42 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2023 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20230809130640

FACILITY NAME:	MOUNTAIN VIEW ASSISTED LIVING		FACILITY NUMBER:	236803448
ADMINISTRATOR:	JEANNETTE KINNEY		FACILITY TYPE:	740
ADDRESS:	1343 S DORA ST		TELEPHONE:	(707) 462-6212
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	64	CENSUS:	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:			TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Administrator not providing written response to Resident Council

INVESTIGATION FINDINGS:

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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigaiton into the above allegation. LPA met with Executive Director Alexandria Rodriguez and reviewed records. LPA reviewed resident council minutes for February thru August, 2023. LPA observed the only written response for this time frame was June. ***This is a second violation of the same regulation in a 12 month period. An immediate civil penalty is being issued in the amount of $250.*** LPA requested Licensee to update the facility policy for Resident Councils to address the process of where Council minutes are sent and the process facility takes to ensure the Executive Director receives and responds to the Council in writing. Based on the Departments investigation, the preponderance of evidence...
Continued on LIC9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230809130640

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2023 Section Cited HSC 1569.157(c)	1 2 3 4 5 6 7	§1569.157 Resident-oriented facility council:(c)If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response	1 2 3 4 5 6 7	Licensee to respond to resident council concerns or recommendations in writting within 14 calendar days. Facility to send a copy of Resident Council minute responses to CCLD at the time they are provided to the
	8 9 10 11 12 13 14	to those concerns or recommendations within 14 calendar days. This requirement is not met as evidenced by: Based on interviews conducted, Director did not respond in writing per regulation.	8 9 10 11 12 13 14	resident council. Copies of Council responses sent to CCLD to commence by POC date of 8/14/2023 and continue for 1 year.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230809130640

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/10/2023

NARRATIVE

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standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
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 Executive Director and Appeal rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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