<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002836
Report Date: 11/12/2021
Date Signed: 11/12/2021 01:14:28 PM

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:SIERRA VIEW SENIOR LIVINGFACILITY NUMBER:
295002836
ADMINISTRATOR:WINGET, LISA VIXIEFACILITY TYPE:
740
ADDRESS:120 DORSEY DRIVETELEPHONE:
(530) 273-4849
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:49CENSUS: 27DATE:
11/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lisa Vixie WingetTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/12/2021 at 10:45 AM Licensing Program Analysts (LPA) Lusby arrived to conduct the prelicensing inspection. Prior to the visit, 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; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95.

LPA and Administrator completed the prelicensing inspection tool domain and the facility was found to be in substantial compliance. LPA and Administrator conducted a walk through of the facility and ensured all physical plant requirements.

Component III was conducted and completed with Administrator. LPA will notify CAB that the facility is ready for licensure.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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 1