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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 08/09/2022
Date Signed: 08/09/2022 12:29:50 PM


Document Has Been Signed on 08/09/2022 12:29 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:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 10DATE:
08/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Darrell PriceTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/9/22 to conduct a Case Management Inspection. LPA met with staff and explained the purpose of the visit. Prior to initiating the visit, 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 and contacted licensee. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior of the facility . In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Executive Director (ED), Price discussed the facility's plans to no longer pursue building modifications to increase non-ambulatory capacity due to prohibitive costs. Licensee will continue fire watches as agreed to until there is one non-ambulatory resident remaining. There are currently 5 non-ambulatory residents.
ED provided LPA with requested documents.
Licensee will continue to update CCL.

Licensee and ED agreed to update the facility's administrator designee.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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