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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:17:02 PM


Document Has Been Signed on 04/30/2024 02:17 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:ZENIA SHAHFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 41DATE:
04/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Zenia ShahTIME COMPLETED:
02:30 PM
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While conducting a complaint visit on this date, Licensing Program Analyst (LPA) Chris Arnhold followed up on an Unusual Incident Report regarding an incident that occurred on 04/05/2024. Resident (R1), was seen walking to an activity at approximately 3:00PM on 04/05/2024. At approximately 3:15PM, R1 was observed by staff at the facility. At approximately 3:25PM, Sonia Sandoval, Business Office Manager, received a telephone call from Ukiah Post Acute, a medical facility next door to this facility, asking if R1 was from the facility. A staff member immediately went to retrieve R1.
LPA reviewed facility files and observed the initial assessment for R1 did not list any wandering behaviors and the physician report stated R1 was able to leave the facility without assistance. Upon the return of R1, facility updated residents care plan and placed resident on frequent checks.
LPA observed facility followed regulation and updated the care plan when observed changes occurred.

No citations issued as a result of this incident.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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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