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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 05/08/2024
Date Signed: 05/08/2024 09:44:20 AM


Document Has Been Signed on 05/08/2024 09:44 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:DARRELL PRICEFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(916) 488-7211
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 12DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:CELESTE GIULIANO-LAUI TIME COMPLETED:
09:47 AM
NARRATIVE
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On 5/8/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 5/6/2024. LPA met with Med Tech, and explained the purpose of the visit.

During today's visit, Administrator and Residential Care Director was unavailable. LPA spoke with Residential Care Director via telephone during LPA's visit to conduct interview and explain the purpose of the visit.

The incident occurred on 5/5/2024 at approximately 1:30 PM when facility staff observed R1 to be missing during rounds. Facility staff then contacted Residential Care Director, who then found R1 "a few blocks from facility" with alcohol and was observed to be impaired beyond baseline. Based on R1's LIC 602 Physician's Report, signed on 2/18/2024, indicated that R1 was deemed unable to leave the facility unassisted.

LPA and Residential Care Director discussed having the appropriate number of staff to ensure the care and supervision of residents in care are being met. Additionally, LPA and Residential Care Director discussed this incident may have been a new placement trauma which caused R1 to flight. Residential Care Director stated a conference call be made to elaborate the reasoning why R1 is unable to leave facility unassisted.

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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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Document Has Been Signed on 05/08/2024 09:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RESIDENCE
FACILITY NUMBER: 347005580

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
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.

Plan of Correction is to be faxed to CCLD by 5/9/2023.
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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 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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