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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:31:26 PM


Document Has Been Signed on 06/16/2022 03:31 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 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: 13DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Kim JacksonTIME COMPLETED:
03:45 PM
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On 06/16/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required-1 Year Inspection. LPA met with Director, Kim Jackson, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPA and Director toured the interior of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, med room and laundry room. LPA observed toxics, medication and sharps to be secured in locked areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Director followed the infection control domain guidelines and facility was found to be in substantial compliance at this time.

LPA reviewed a record resident visitation log. LPA observed the (2) fire extinguishers to be monthly inspected. Director inquired LPA about the usage of surgical masks for unvaccinated staff with medical/religious exemptions.

LPA was provided a copy of the Administrator Certificate #6050752740 which was up to date: expiration date of 12/13/2022. LPA was provided a copy of the Certificate of Liability Insurance policy effective 2/1/2022 and expired 2/1/2023.

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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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