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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 05/22/2025
Date Signed: 05/22/2025 02:18:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250401122959
FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR:ZENIA SHAHFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 42DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Zenia ShahTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are mismanaging residents medication
Staff are not meeting residents dietary needs
Staff are not ensuring residents have activities
Staff are not providing adequate food service to resident's
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Zenia Shah, interviewed staff and reviewed records. Based on records reviewed and interviews conducted, LPA observed Resident, R1, did not receive assistance with a medication as ordered by physician. Medication was to be given 30-60 minutes prior to the first meal of the day. Medication was listed on the Medication Administration records (MAR) to be given at 6AM when breakfast is served at 8:30AM. A medicated cream was to be applied twice daily for 14 days and records indicate it was not applied 3 times during that 14 day period.
Based on records reviewed and interviews conducted, Resident, R2, had an order for a low acid diet that was not provided to the dining staff. This resulted in R2 receiving food items that were not in line with physician orders. Based on records reviewed and visual observation, activities were scheduled and cancelled
on a routine basis. This allegation was addressed on 04/22/2025.
Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250401122959

FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR:ZENIA SHAHFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 42DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Zenia ShahTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are charging resident for services not needed
Staff did not safeguard residents personal belongings
Staff are not meeting resident's toileting needs
Staff are not meeting resident's hygiene needs
Staff are not providing a comfortable environment for residents
INVESTIGATION FINDINGS:
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Zenia Shah, interviewed staff and reviewed records. Based on records reviewed and interviews conducted, facility staff observed R1 was requiring additional assistance with care needs. Facility increased care costs and met with responsible party. An agreement was made to refund care costs for a trial period to further assess R1. LPA reviewed personal property inventories and observed R1 did not have items listed. Facility staff attempt to keep track of personal items in line with the facilities theft and loss policy. Based on interviews conducted and records reviewed, LPA was not able to find evidence to support the allegations that staff were not meeting resident toileting or Hygiene needs. Residents R1 and R2 require miminal assistance with toileting and bathing. Facility documents when care is provided. Based on interviews conduced, LPA was not able to find evidence to support the allegation that staff were not providing a comfortable environment for residents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250401122959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236803448
VISIT DATE: 05/22/2025
NARRATIVE
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Based on records reviewed and interviews conducted, facility was utilizing care giving staff to serve meals during meal times. This practice led to a lack of care giving support to the residents that did not attend the dining room. Facility did not have sufficient dining aides to assist residents for meals. This allegation was address on 04/22/2025. Executive Director has hired several dining room attendants and care giving staff.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
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 Zenia Shah and Appeal rights were given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250401122959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2025
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 interviews conducted and records reviewed, staff did not assist residents with medication as ordered by physician, which
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Facility corrected the administration time for medications and conducted training for medication technicians on the new computer system being implemented. Violation cleared during visit.
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poses an Immediate Health, Safety or Personal Rights risk to persons in care.
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Type B
06/06/2025
Section Cited
CCR
87555(7)
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87555 General Food Service Requirements:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on records reviewed, R2 has an order for a low acid diet that the kitchen did not have
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Licensee will meet with dining director to review diet orders and develop a plan to ensure communication is clear between dining and resident services. Plan to be submitted to CCL by 06/06/2025.
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record of. This poses a potential Safety, Health or Personal Rights risk to persons 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4