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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:57:54 PM


Document Has Been Signed on 07/11/2022 12:57 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:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 36DATE:
07/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Angie SmithTIME COMPLETED:
01:15 PM
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At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to several incident reports submitted to CCL. LPA met with Executive Director Angie Smith and reviewed records.

Incident 1 involved a resident having several aggressive outbursts with staff and other residents and several falls. Facility contacted the physician to review medications. Responsible party was notified. Facility scheduled additional staff to ensure the safety of residents and staff. Facility updated care plan to address behaviors and will continue to follow physician orders.

Incident 2 involved a submitted SOC341, report of suspected elder abuse on 06/01/2022. Resident told staff they had been raped. Facility contacted local law enforcement and responsible party. Resident refused to be taken to the hospital and told staff they did not want to make a big deal of the incident. Law Enforcement interviewed resident later the same day and resident did not have knowledge of reporting the incident or that it occurred.

LPA received copies of documents.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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