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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 05/05/2022
Date Signed: 05/05/2022 06:09:53 PM

Document Has Been Signed on 05/05/2022 06:09 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 64CENSUS: 37DATE:
05/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Angie SmithTIME COMPLETED:
06:15 PM
NARRATIVE
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While conducting a complaint investigation, Licensing Program Analyst (LPA) Chris Arnhold observed the following violations. LPA reviewed hospice documentation and observed a care plan requiring 2 staff to provide assistance at all times while resident was being assisted with bathing. Due to staffing levels, staff would assist at the beginning of a shower, then leave only 1 staff in shower room, then return later to assist after shower was completed.

LPA observed that several activities scheduled during the months of March and April were not conducted due to lack of staff. On April 7, 2022, facility caregivers were instructed to conduct activities instead of providing assistance with the needs of residents. Based on interviews conducted, those activities were not conducted due to lack of staff.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


This report was reviewed with Angie Smith and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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Document Has Been Signed on 05/05/2022 06:09 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 05/05/2022 at 04:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236803448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87633

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87633 Hospice Care of Terminally Ill Residents:(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times.
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Licensee to ensure hospice care plans are followed by facility. Training to be conducted with all care staff regarding Hospice care and the responsibilities of care providers. Completed training
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This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not follow a hospice care plan. This poses a potential health or safety risk to residents.
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sign in roster to be submitted to CCL by POC date of 05/31/2022.
Type B
05/31/2022
Section Cited
CCR87219

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87219 Planned Activities:(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not
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Licensee to ensure activities are planned and organized to encourage residents to participate. Licensee to submit a weekly list of activities completed, both in memory care and assisted living.
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met as evidenced by: Based on interviews conducted, Activities are not conducted as scheduled or not conducted in a manner engaging to residents. This poses a potential health risk to residents in care.
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List to be sent weekly to CCL through 2022.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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