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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002836
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:00:41 PM


Document Has Been Signed on 10/12/2023 04:00 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 33DATE:
10/12/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lisa Vixie WingetTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced to conduct a collateral visit. LPA interviewed Administrator and R1 on an issue that was not related to this facility.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Exit Interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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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