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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803448
Report Date: 04/01/2026
Date Signed: 04/01/2026 02:13:28 PM

Document Has Been Signed on 04/01/2026 02:13 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
SANTA ROSA RO, 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) 532-0678
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 64CENSUS: 48DATE:
04/01/2026
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Zenia ShahTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived announced, to conduct a pre-licensing inspection due to an ownership change of this currently operating care facility for the elderly. During this inspection, LPA followed up on four SOC341, Report of Suspected Dependent Adult/Elder abuse forms and an incident report. LPA met with Executive Director Zenia Shah and reviewed records.

Two of the SOC341 forms and the Incident report were regarding a medication error that occurred on 02/02/2026. LPA spoke with Executive Director about reporting requirements and that an SOC341 was not required for medication errors. The error involved two residents, R1, R2, and them reporting to the medication staff, S2, that they did not receive their medication that morning from the previous medication staff, S1. S2 reviewed the computer system and found the medication was marked as given. An internal investigation was conducted and discovered S1 did not give the medication but marked it as given in the system. The physician was notified and authorized the medication to be given, even though it was past the normal time. Facility conducted additional training for all medication staff to refresh procedural knowledge and additional audits were put into place to ensure medications are given as ordered. ***This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250.***

An SOC341 was submitted regarding Resident, R3, leaving the building without staff escort and assaulting staff. LPA reviewed records and interviewed staff and observed R3 left the memory care door and entered the outside courtyard. Staff observed R3 in the courtyard and immediately followed R3 and requested they come back inside. Staff had visual line of sight with resident during this incident. The door leading to the courtyard has an audio alert device, but the volume was low. Facility maintenance is working to increase the alert volume.

Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/01/2026 02:13 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 04/01/2026 at 12:44 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: 04/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2026
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 and interviews conducted, Licensee did not ensure medication was given as ordered. This poses
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Licensee ensured additional medication training was completed. Staff responsible was terminated for falsifying records. POC cleared during visit.
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an Immediate Safety, Health or Personal Rights risk to persons in care. ***This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250.***
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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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236803448
VISIT DATE: 04/01/2026
NARRATIVE
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An SOC341 was submitted regarding Resident, R4, telling staff, S3, that a caregiver, S4, had grabbed them and pushed them toward the bed, then left the room. The facility conducted an investigation and found that throughout the day, R4, told staff a different story, including that staff were throwing the children against the closet doors. The investigation showed that R4 would describe the caregiver they saw last as the perpetrator of each incident. 02/20/2026 at approximately 12:00PM, R4 used their call button to summon staff and when staff entered, R4 immediately stated "Ow, your're hurting me!" Staff did not enter the room and immediately notified their supervisor of the situation. R4 was examined and no signs of abuse were found. Care plan was updated to ensure 2 staff are present at all times when assisting R4.

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.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC809 (FAS) - (06/04)
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