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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 12/02/2024
Date Signed: 12/02/2024 11:49:31 AM

Document Has Been Signed on 12/02/2024 11:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR/
DIRECTOR:
ZENIA SHAHFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 64CENSUS: 47DATE:
12/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Zenia ShahTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a report of alleged theft in the building. LPA met with Executive Director Zenia Shah and reviewed records. On 11/13/2024, Zenia informed LPA a resident reported money being stolen from their room. An investigation was conducted and staff were interviewed. No staff reported seeing the money. Zenia contacted law enforcement, but resident declined to speak with them. Based on records reviewed, there were two other situations in the last 12 months when resident believed items were taken and nothing was found. Facility followed their theft policy and reported the incident as required by regulation.

No citations issued during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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