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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 08/17/2021
Date Signed: 08/17/2021 06:10:25 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 MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR:JAMES JORDANFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(916) 488-7211
CITY:FAIR OAKSSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 15DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jessica Wallace, Resident Care Director and Darrell Price, Executive Director TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Jessica Wallace, Resident Care Director and Darrell Price, Executive Director, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask.

LPA, Resident Care Director and Executive Director toured and observed the Assisted Living section/wing of the building to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, (16) shared resident bedrooms, (1) private resident bedroom, shower room, medication room, dining room, and visitor room. In the areas toured, there were no immediate health, safety, or personal rights violations observed. LPA , Resident Care Director and Executive Director completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 74* F.

Executive Director provided an update on the status of the pending upgrades required by fire to increase the non-ambulatory waiver. Specifically, the facility has obtained the approved plans for the contractor and is waiting on a final building permit to begin the construction improvements, dry wall work, HVAC needed in corridors and a new fire alarm system. Executive Director and a staff member explained that hourly checks are done inside and outside the building to ensure there are no fires as requested by fire since the building is not up to current code. Construction is anticipated to start in September 2021 and to be completed in November 2021.

There were no deficiencies found during today's inspection.
Exit interview. Copy of report to be e-mailed to Executive Director by end of today.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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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