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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 02/24/2025
Date Signed: 02/24/2025 12:38:52 PM

Document Has Been Signed on 02/24/2025 12:38 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/
DIRECTOR:		ZENIA SHAHFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 64CENSUS: 44DATE:
02/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jeramie WagerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an SOC341, Report of suspected elderly/dependant adult abuse form, a report of an elopement and a report of a medication error. LPA met with Environmental Director Jeramie Wager, toured the building and reviewed records.
Incident 1: The SOC341 form was submitted by the Executive Director on 02/18/2025. On 02/17/2025, Residents, R1, family arrived to visit and observed R1 had not been repositioned or assisted out of bed. The family brought this to the attention of staff, S1, who stated they would not assist resident. Family informed the medication technician, who in turn reported this to the Executive Director. S1 was placed on suspension pending an investigation and retraining was done with all staff on Abuse and Neglect. LPA provided Declaration forms to staff witnesses.
Incident 2: The facility submitted an unusual incident report on 11/25/2024 regarding an elopement that occurred on 11/22/2024. At approximately 11:45AM, while residents were gathering for lunch, staff could not locate Resident, R2. Staff searched the building to no avail and law enforcement was notified and a photo was provided. Management drove around the local area to search for R2. At approximately 12:43PM, Law Enforcement notified facility R2 had been located safe and unharmed, approximately 1 mile from the facility. Care plan was updated and resident was moved to a more secure location. Retraining on Elopement, Hospice, Tone and Call lights was completed with staff on 11/22/2024.
Incident 3: The facility submitted an unusual incident report on 12/23/2024 regarding a medication error. On 12/09/2024, medication technician made an error in giving Resident, R3 the wrong dose of medication. Medication technician informed the facility nurse of the error. Resident did not have any adverse effects. Changes were made to the medication procedures to ensure medication errors do not continue.
LPA requested the following documents and are to be submitted by 03/07/2025:
-Documents regarding investigation for S1 refusing to assist resident.
-Copy of staff file for S1, including training record.
-Written Declaration forms from all staff witnesses.
Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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 02/24/2025 12:38 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 02/24/2025 at 08:45 AM
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: 02/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure resident received the proper dose of medication as ordered. This poses an
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Executive Director revised the medication procedure to ensure the small differences in medications are more noticeable for staff. POC cleared at time of visit.
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immediate Health risk to residents in care.
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Type A
02/25/2025
Section Cited
CCR87705(e)(5)

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87705 Care of Persons with Dementia:(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated
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Executive Director conducted retraining for staff on Elopement protocols and worked with responsible party to move resident to a more secure location. POC cleared at time of visit.
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Facilities. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure the continued safety of resident. Resident left facility without staff knowledge or assistance. This poses an immediate 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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2025 12:38 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 02/24/2025 at 10:49 AM
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: 02/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
HSC
1569.269

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1569.269 Enumerated rights; severability:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on records reviewed
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Executive Director suspended staff responsible and conducted retraining for staff on Abuse and Neglect. POC cleared at time of visit.
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Licensee did not ensure resident received the services to meet their needs, due to staff refusing to assist. This poses an Immediate Health, Safety or Personal Rights risk to 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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 236803448
VISIT DATE: 02/24/2025
NARRATIVE
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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 Jeramie Wager and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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