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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701011
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:59:59 PM


Document Has Been Signed on 05/15/2023 02:59 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 5DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Sayeh JacksonTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on May 15 ,2023 to conduct the annual inspection. LPA met with Sayeh Jackson, Administrator and explained the purpose of the visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (2). All resident files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. All required posting were observed. Staff training contained the required initial training.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 05/25/23.

No deficiency cited during today's visit. Exit interview conducted .
A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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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