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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701011
Report Date: 03/24/2022
Date Signed: 03/24/2022 01:06:11 PM


Document Has Been Signed on 03/24/2022 01:06 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
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:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Sayeh JacksonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced on 03/24/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA and ,LPM met with Administrator, Sayeh Jackson , and explained the purpose of the visit. Prior to initiating the annual inspection, LPA and LPM completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA and LPM wore the following Personal Protective Equipment (PPE) during today's visit: surgical masks. LPA and LPM were screened by administrator before entry to facility.

LPA, LPM and Administrator toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, six (6) bedrooms, three (3) bathrooms, medication closet , garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today's inspection.
Exit interview conducted and copy of report left at the facility.




SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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