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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005580
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:54:11 PM


Document Has Been Signed on 07/16/2024 03:54 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: 11DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:CELESTE GIULIANO-LAUI & KIM JACKSONTIME COMPLETED:
04:00 PM
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On 07/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Med Tech and explained the purpose of the visit, who then contacted Residential Care Director who arrived to the facility shortly afterwards. Census is one (1) non-ambulatory resident, 10 ambulatory residents, and zero residents on hospice services. Facility is licensed for 1 non-ambulatory, 32 ambulatory residents, hospice waiver of 1.

During today's visit, LPA and Residential Care Director conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: dining room, medication room, five residents room and the common areas. LPA observed kitchen to be fully staffed with cooks, where residents are unable to enter to access sharps. Laundry room is kept locked at all times. LPA observed medication carts to be locked and inaccessible to residents in care. LPA conducted a random medication count for four residents in care. LPA observed medications to be accounted for.

File review was conducted for five residents files and five personnel files. LPA observed the required documents present in file. Additionally, LPA provided facility a copy of §1569.625 Staff training; legislative findings; contents and §1569.312 Basic services requirements.

LPA and Residential Care Coordinator discussed conservatorship of R1. LPA advised facility to keep documentation of facility attempts and contacting county judge if needed. Residential Care Coordinator reported no additional concerns at the moment.

At this time, LPA is requesting a copy of facility liability insurance and LIC 500 by Monday July 22, 2024. No deficiencies observed.

Exit interview and a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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