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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 04:00:12 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lisa Vixie WingetTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday October 12, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (7) and staff (7) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills.

LPA, Administrator, and Wellness Director toured the facility together to ensure the health and safety of residents in care. The areas toured included apartments, lobby, kitchen, medication room, and courtyard. LPA observed the facility's PPE storage. Facility is clean and well organized. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPA obtained an updated copies of LIC500, LIC610E and current liability insurance.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
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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