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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804373
Report Date: 04/01/2026
Date Signed: 04/01/2026 02:20:06 PM

Document Has Been Signed on 04/01/2026 02:20 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236804373
ADMINISTRATOR/
DIRECTOR:		SHAH, ZENIAFACILITY TYPE:
740
ADDRESS:1343 S DORA ST.TELEPHONE:
(707) 532-0678
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 64CENSUS: 48DATE:
04/01/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Zenia ShahTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived announced, to conduct a pre-licensing inspection due to an ownership change of this currently operating care facility for the elderly. The current management company will continue to manage the facility operations. LPA met with Administrator Zenia Shah and Applicant representative Jessica Lasswell. The facility is requesting a total capacity of 64 with 57 non-ambulatory residents and 7 bedridden residents. All rooms are approved for bedridden or Non-Ambulatory residents. The facility is a single-story building with a 10 resident capacity in the Memory Care unit. The facility has requested a hospice waiver for up to 5 residents.

The facility has a large courtyard in the center of the facility, and a closed-in outdoor patio in the memory care unit. Random rooms were inspected in the Assisted Living and memory care areas of the facility. The indoor temperature was 72 degrees. All personal accommodations were present in the inspected rooms. The facility staffs a receptionist at the main entrance. LPA observed facility hallways were unobstructed, and the facility smelled clean. Exits were clearly marked. LPA observed the interior doors of the memory care unit were locked with a keypad and were not delayed egress. The doors unlock in case of fire alarm activation or a power outage. LPA contacted the Fire Marshal's office for clarification.

Facility cleaners and toxins are stored in the locked housekeeping supply room. Housekeeping carts are lockable and were found to be locked while in use. LPA observed the required amounts of perishable and nonperishable foods. The kitchen and dining area were clean and well maintained. Water temperature measured within regulation between 105 and 120 degrees F at various resident bathrooms and accessible faucets. LPA observed the facility has a hard wired fire alarm system, and has appropriate smoke and carbon monoxide alarms in place. Medication is centrally stored and locked in a dedicated medication room in the assisted living section of the building. Resident medical records are also kept locked and inaccessible in this room.

Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236804373
VISIT DATE: 04/01/2026
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The facility has multiple pull station fire alarm with audio/visual alerts, and all resident bathrooms have pull cords for alerting staff for assistance. Residents also receive a pendant to keep with them. All fire extinguishers are charged and currently tagged. The fire system is checked annually.

LPA and the Executive Director discussed the facility's emergency disaster preparedness plan for the individual facility needs and the disaster plan for a large scale disaster which may affect city/county. Facility has supplies to be self sufficient for at least 72 hours. Facility has a generator to supply power for select items during an outage. Staff have hand held radios to communicate during a power outage or emergency and residents are provided hand held bells to call for assistance during a power outage.

Executive Director and applicant have successfully completed the Component lll Orientation section of the application process.

Applicant will provide evidence of Liability insurance once the License has been awarded.



LPA will submit the application packet for a final review and approval from the Licensing Program Manager.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC809 (FAS) - (06/04)
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