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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 08/16/2023
Date Signed: 08/16/2023 02:08:11 PM


Document Has Been Signed on 08/16/2023 02:08 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MOUNTAIN MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR:DARRELL PRICEFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(916) 488-7211
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 10DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Darrell Price and Kim JacksonTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on 8/16/2023 to conduct a Required Year Inspection utilizing the CARE inspection tool. LPA met with Administrator, Darrell Price and Director, Kim Jackson, and explained the purpose of the visit .

Facility is licensed for 32 ambulatory and 1 non-ambulatory. LPA was informed facility currently has 1 non-ambulatory resident, which is compliance to licensure.

LPA toured the interior of the facility together with Director to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, dining room and med room. In the areas toured no immediate health, safety, or personal rights violations were observed.

During today's inspection, LPA reviewed (5) resident files and (5) staff files. LPA observed staff files to be complete with the required medication training. LPA observed resident files were found to be complete with updated medical assessments.

LPA observed Administrator Certificate to be expired. LPA and Administrator discussed the backlog of Administrator Certificate renewal. LPA observed Administrator's name present in the pending list on CCLD website. Additional, LPA and Director discussed the concern of an AWOL resident, LPA was informed LIC624-Incident Report will be submitted to CCLD.

At this time, LPA requested a copy of LIC 500-Personnel Report, LIC 308-Designation of Responsibility and liability insurance to be emailed to LPA by Wednesday August 23, 2023.

No deficiencies observed. Exit interview conducted with Director. Copy of this report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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