236803448-4-30-2024-21-AS-BMOS-D7WTEE-20240807143946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:15:53 PM

Unsubstantiated

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
03/18/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20240318141105

FACILITY NAME:	MOUNTAIN VIEW ASSISTED LIVING		FACILITY NUMBER:	236803448
ADMINISTRATOR:	ALEXANDRIA RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	1343 S DORA ST		TELEPHONE:	(707) 462-6212
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	64	CENSUS: 41	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Executive Director Zenia Shah		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not safeguarding the residents personal belongings
Staff are not meeting the residents dietary needs
Staff are not keeping the facility free from pests
Staff are not prepared for an emergency disaster

INVESTIGATION FINDINGS:

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At approximately 9:35AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Executive Director Zenia Shah and reviewed records. LPA received copies of documents. Based on interviews conducted and records reviewed, facility has a theft/loss policy that is included with the Admission agreement and employee handbook. On 11/07/2023, Resident, R1, reported money was taken from their room. Facility followed their policy and conducted an investigation and notified Law Enforcement. The investigation did not reveal any further information and there have not been anymore reports of theft. LPA reviewed resident council meeting minutes, facility menu's and special diet orders in the kitchen. LPA was not able to find any supporting evidence regarding resident dietary needs not being met. Continued on LIC9099-C...

Unsubstantiated

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240318141105

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: 04/30/2024

NARRATIVE

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Based on records reviewed and interviews conducted, facility has a contract with Terminix to provide ongoing pest prevention. LPA reviewed monthly service statements and did not observe any reports of concern. LPA toured the building and grounds and did not observe evidence of pests. LPA did not find evidence to support the allegation that staff are not keeping the facility free from pests.
LPA reviewed facilities emergency disaster plan and emergency drill records. Facility conducts drills monthly and has a current emergency disaster plan. LPA did not find evidence to support the allegation that staff are not prepared for an emergency disaster.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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