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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701011
Report Date: 04/05/2021
Date Signed: 04/05/2021 10:53:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:MOUNTAIN VIEW SENIOR CARE, LLCFACILITY NUMBER:
312701011
ADMINISTRATOR:JACKSON, SAYEHFACILITY TYPE:
740
ADDRESS:3755 MOUNTAIN VIEW DRTELEPHONE:
(916) 893-3099
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: DATE:
04/05/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sayeh JacksonTIME COMPLETED:
10:00 AM
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Facility Type: RCFE
Application Type: Change of Ownership
Capacity: 6
Census (if any clients in care): 6
Method: Telephone call with CAB
COMP II Participants: Shay Jackson

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
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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