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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002836
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:20:29 PM


Document Has Been Signed on 01/06/2023 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
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: 34DATE:
01/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lisa Winget, Administrator TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada conducted an unannounced case management visit on 01/06/2023. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility.

LPA met with Administrator and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 01/06/2023 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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