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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295001794
Report Date: 05/24/2022
Date Signed: 05/24/2022 03:39:29 PM


Document Has Been Signed on 05/24/2022 03:39 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:MOUNTAIN VIEW CARE HOMEFACILITY NUMBER:
295001794
ADMINISTRATOR:BRITTANY ALLEYFACILITY TYPE:
740
ADDRESS:10619 SIERRA DRIVETELEPHONE:
(530) 273-7820
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 14DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brittany AlleyTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 05/24/2022 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Administrator, Brittany Alley, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, thirteen (13) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Facility is undergoing numerous facelifts including new rails and stairways.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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