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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002836
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:00:03 PM

Document Has Been Signed on 11/06/2024 02:00 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/
DIRECTOR:		WINGET, LISA VIXIEFACILITY TYPE:
740
ADDRESS:120 DORSEY DRIVETELEPHONE:
(530) 273-4849
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 49CENSUS: DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Lisa Vixie WingetTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kerry Hiratsuka conducted the unannounced annual inspection.

LPA and Administrator 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.

Multiple topics discussed.

No deficiencies cited. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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