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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295920098
Report Date: 04/29/2024
Date Signed: 04/29/2024 11:21:46 AM


Document Has Been Signed on 04/29/2024 11:21 AM - 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:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
295920098
ADMINISTRATOR:LOCKHART, BRITTANYFACILITY TYPE:
740
ADDRESS:10619 SIERRA DR.TELEPHONE:
(530) 273-7820
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 14DATE:
04/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brittany LockhardTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday April 29, 2024 to conduct an unannounced prelicensing visit. This is a change of ownership with residents in care.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. LPA reviewed 7 resident files and 4 staff files. All files contained the required paperwork. This facility has a fire clearance for 5 ambulatory and 9 nonambulatory residents, with a total capacity of 14. Facility has all required postings in the hallway.

LPA toured the facility with owners Brittany and Corey. The following areas were inspected for compliance: kitchen, resident rooms, bathrooms, backyard, and common areas. Facility has current fire extinguishers, PPE, and fully stocked first aid kit. Medications are kept locked in a cabinet in the office. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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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