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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 05/22/2025
Date Signed: 05/22/2025 09:59:37 AM

Document Has Been Signed on 05/22/2025 09:59 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 MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR/
DIRECTOR:		DARRELL PRICEFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(916) 488-7211
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 33CENSUS: 15DATE:
05/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator, Darrel Price TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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On 05/22/25, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 05/13/25. LPA met with Administrator, Darrel Price and explained the purpose of the visit.

The incident occurred on 05/11/25 at approximately 9:30 AM when facility staff observed resident, R1 to be missing during rounds. Facility staff searched in the facility but was not successful. R1 returned around 11:30 AM and told staff that they went to church without notifying anyone at the facility with their roommate. Based on R1's ,LIC 602 Physician's Report, signed on 11/06/24 indicated that R1 was deemed unable to leave the facility unassisted. Record review indicated that R1 was residing at the facility since 05/03/24 and were on staff check list for hourly monitor prior to this incident. Staff stated that facility has increased R1’s safety check every 30 minutes/daytime and every hour /night time to ensure R1s health and safety after this incident. Facility notified R1s responsible party, physician and other required parties regarding this incident.

LPA and administrator discussed having the appropriate number of staff to ensure the care and supervision of residents in care are being met.

As a result of the incident, deficiencies cited. Please see LIC 809-D, per Title 22 Regulations.

Exit interview conducted, a copy of the report and appeal rights provided to facility staff. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Talwinder Bains
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/22/2025 09:59 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/22/2025 at 07:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MOUNTAIN MANOR SENIOR RESIDENCE
FACILITY NUMBER: 347005580

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by:
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Licensee is to submit a plan of how facility will ensure residents' care and supervision are met and shall conduct staff training.

Plan of Correction is to be sent to CCLD by 05/23/25.
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Based on file review, Licensee did not comply with the section cited above as R1 was observed by a facility staff to be leaving the facility unassisted on 05/11/25 when R1's LIC 602 stated R1 cannot leave facility unassisted which poses an immediate health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
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