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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701011
Report Date: 04/14/2021
Date Signed: 04/14/2021 04:56:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 6DATE:
04/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sayeh Jackson, AdministratorTIME COMPLETED:
05:30 PM
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On 04/14/2021 at 2:00 PM Licensing Program Analyst (LPA) Jasmine McCrory conducted a pre-licensing inspection via facetime due to COVID-19 precautionary reasons with Sayeh Jackson, Administrator, who assisted in conducting this inspection.

LPA and Admin toured the following areas, including but not limited to: common areas, kitchen, bedrooms and bathrooms. At time of inspection, all common areas were free from hazards, clean and in good repair. LPA observed that the Fire extinguisher date 03/21/2021 is current and First Aid kit is fully stocked.

Kitchen was clean and in good repair. Facility is prepared to provide (7) seven days of non-perishable food required for emergency shelter in place supplies. The facility has 6 Bedrooms which were found in good repair with required furniture. Water temperature was tested in front full bathroom and measured at 107.5 degrees F, water temperature was tested in half bathroom at 107.5 degrees F, also tested in the kitchen and measured at 107.5 degrees F, all of which are within the required range of 105-120 degrees F.

Facility will accept total capacity of (6) six non-ambulatory residents per the approved fire clearance dated 03/24/2021 by Rocklin Fire Department. All common areas appear to be free from hazards, clean and in good repair. As of this date, the Department has received the fire clearance.

During this inspection, this facility complies and meets the minimum requirements for a Residential Care Facility for the Elderly (RCFE) license. Component III was completed during this visit with Administrator. Pre-licensing Inspection is complete, and this facility has no deficiencies.

Exit interview held with Administrator at 5:00 PM and a copy of this report was given via email at the conclusion of the visit.

Currently, this application is pending further review.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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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