Inspection Reports for Mountain View Assisted Living & Memory Care
1343 S Dora St, Ukiah, CA 95482, United States, CA, 95482
Back to Facility ProfileInspection Report Summary
Most inspections at Mountain View Assisted Living Facility found no deficiencies, including the most recent report on October 28, 2025, which was clean. However, some earlier reports documented issues primarily related to inadequate staffing, failure to report incidents properly, and resident safety concerns such as elopements and medication errors. Several complaint investigations were substantiated, particularly those involving insufficient staff to meet resident needs and missed or cancelled activities, while many other complaints were unsubstantiated. The facility received a $250 fine in August 2023 for failing to respond in writing to the Resident Council’s concerns. Recent inspections show improvement with no deficiencies cited in the last two visits, indicating progress in addressing prior issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
78% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 50
Capacity: 64
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
The visit was an unannounced case management inspection to conduct interviews and review documents regarding three incidents reported by the facility.
Findings
No citations or deficiencies were issued during this visit after review and interviews conducted by the Licensing Program Analyst.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sonia Sandoval | Business Office Manager | Met with Licensing Program Analyst during the inspection. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and interviews. |
| Zenia Shah | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Monitoring
Census: 50
Capacity: 64
Deficiencies: 0
Date: Sep 26, 2025
Visit Reason
An unannounced case management visit was conducted to gather documents regarding former employees and to review records.
Findings
No citations or deficiencies were issued during this visit. The Licensing Program Analyst reviewed documents and plans to return for additional interviews.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during the visit and involved in document review. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and document review. |
Inspection Report
Census: 47
Capacity: 64
Deficiencies: 2
Date: Aug 12, 2025
Visit Reason
The visit was an unannounced case management inspection to investigate the reduction in the number of Unusual Incident Reports (SIRs) submitted by the facility.
Findings
The facility generally submitted 8-10 SIRs per month until May 2025, when the number dropped to 3-4. The Licensing Program Analyst found at least 4 incidents requiring emergency personnel that were not reported to the licensing agency. Additionally, a recent resident elopement was reported and addressed with updated care plans and staff training guidance.
Deficiencies (2)
Licensee did not ensure staff were aware when a resident left the building without assistance, posing an immediate health, safety, or personal rights risk to persons in care.
Licensee did not submit written reports regarding residents who required emergency medical care, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Unusual Incident Reports (SIRs) per month: 8
Unusual Incident Reports (SIRs) per month: 3
Plan of Correction Due Date: Aug 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Zenia Shah | Administrator/Executive Director | Facility administrator met with Licensing Program Analyst during inspection |
| Kimberley Mota | Licensing Program Manager | Reviewed the report |
Inspection Report
Census: 46
Capacity: 64
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to two SOC 341 forms submitted by the facility regarding a former staff member's verbal altercations with residents.
Findings
The Licensing Program Analyst reviewed staff witness statements and the internal investigation related to the incidents. No citations were issued during this visit.
Report Facts
SOC 341 forms: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during the visit and involved in the internal investigation of staff incidents |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 43
Capacity: 64
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
The inspection was an unannounced case management visit to obtain additional information regarding five self-reported incidents involving staff interactions with residents.
Findings
The inspection found that an internal investigation was conducted, resulting in the termination of three staff members. All incidents were properly reported to required parties and the Ukiah Police Department. No deficiencies were cited during the inspection.
Report Facts
Incidents reported: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Administrator | Met with during the inspection and mentioned in relation to the incidents and investigation |
| Carla Martinez | Licensing Program Manager | Conducted the inspection |
| Kimberley Mota | Licensing Program Analyst | Named as Licensing Program Analyst on the report |
Inspection Report
Census: 41
Capacity: 64
Deficiencies: 0
Date: May 30, 2025
Visit Reason
An unannounced case management visit was conducted regarding several SOC341 forms submitted to the department.
Findings
The Licensing Program Analyst met with the Executive Director, reviewed documents, and no citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during the visit. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit. |
Inspection Report
Annual Inspection
Census: 42
Capacity: 64
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection was an unannounced Required-1 Year annual inspection to review staff and resident records, continuing from a prior visit on 04/22/2025.
Findings
The inspection found that resident files contained required documentation and physician visit records, but staff files lacked evidence of completed annual training. Medication storage was secure. Updated facility documents were requested for submission within 30 days.
Deficiencies (1)
Licensee did not comply with training requirements; 5 staff records lacked evidence of completed annual training, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 5
Census: 42
Total capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Administrator | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kimberley Mota | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 49
Capacity: 64
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced Required-1 Year inspection conducted to evaluate the health and safety compliance of the Mountain View Assisted Living Facility.
Findings
The facility was found to be in compliance with health and safety standards during the tour, with no immediate violations observed. Areas including resident rooms, common areas, kitchen, and safety equipment were all in good condition. Due to time constraints, staff and resident records review was deferred to a later date.
Report Facts
Hospice waiver residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Administrator | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 64
Deficiencies: 2
Date: Apr 22, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 2025-03-04 regarding inadequate staffing to meet residents' needs and failure to provide activities to residents.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard after interviews, observations, and records review confirmed inadequate staffing and failure to provide scheduled activities.
Findings
The investigation found that the facility regularly lacked adequate staffing to meet resident needs, including insufficient staff in the memory care area, resulting in extended resident wait times and staff being occupied with meal service. Additionally, activities advertised for memory care residents were routinely cancelled or not conducted as scheduled.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, posing a potential health, safety, or personal rights risk.
Activities were cancelled or not conducted regularly, failing to meet the requirement for planned activities for residents, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 64
Census: 49
Deficiencies cited: 2
Plan of Correction Due Date: May 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Zenia Shah | Executive Director | Facility administrator met during investigation and involved in findings |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 13
Capacity: 14
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted by Licensing Program Analyst Graham Gunby to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, safe, sanitary, and in good condition with all required documents present in resident and staff files. No deficiencies were cited during the inspection.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Lockhart | Administrator | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Graham Gunby | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 64
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by a management change at the facility that was not reported to the Department within the required timeframe.
Complaint Details
The visit was complaint-related due to failure to notify the Department of a management change within the required timeframe. The complaint investigation was unannounced and conducted by Licensing Program Analyst Chris Arnhold.
Findings
The Licensee failed to notify the Department of a management change within the required timeframe as mandated by Health and Safety Code 1569.15, posing a potential risk to health, safety, or personal rights of persons in care.
Deficiencies (1)
Licensee did not notify the Department of a management change within the required timeframe as per Health and Safety Code 1569.15.
Report Facts
Capacity: 64
Census: 47
Plan of Correction Due Date: Apr 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Sonia Sandoval | Business Office Manager | Met with Licensing Program Analyst during the inspection and discussed findings. |
Inspection Report
Annual Inspection
Census: 13
Capacity: 14
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The inspection visit was a required annual and post licensing visit conducted to evaluate the Mountain View Assisted Living Facility's compliance with licensing requirements.
Findings
No deficiencies were cited during the post licensing visit, indicating compliance with applicable licensing standards.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Lockhart | Administrator | Met with the Licensing Program Analyst during the inspection visit. |
| Graham Gunby | Licensing Program Analyst | Conducted the required annual and post licensing visit. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 3
Date: Feb 24, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to a Report of suspected elderly/dependent adult abuse, an elopement report, and a medication error report.
Complaint Details
The visit was complaint-related, triggered by a Report of suspected elderly/dependent adult abuse (SOC341), an elopement incident, and a medication error. The complaint regarding staff refusal to assist a resident was substantiated, resulting in suspension and retraining of the staff member.
Findings
The inspection found that a staff member refused to assist a resident, resulting in suspension and retraining; a resident eloped but was found safe and unharmed; and a medication error occurred where a resident received the wrong dose but had no adverse effects. Deficiencies were cited related to medication administration, resident safety, and staff assistance.
Deficiencies (3)
Licensee did not ensure resident received the proper dose of medication as ordered, posing an immediate health risk.
Licensee did not ensure the continued safety of resident who wandered away from the facility without staff knowledge or assistance, posing an immediate safety risk.
Licensee did not ensure resident received services to meet their needs due to staff refusing to assist, posing an immediate health, safety, or personal rights risk.
Report Facts
Plan of Correction Due Date: 2025
Number of Deficiencies Cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeramie Wager | Environmental Director | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Supervisor for the inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
An unannounced investigation was conducted in response to a complaint alleging that the facility administration was not providing written responses to the Resident Council.
Complaint Details
The complaint alleged that facility administration was not providing written responses to the Resident Council. The allegation was found to be unsubstantiated.
Findings
The investigation found that the facility has been providing written responses to the Resident Council, although the responses were brief and not as detailed as they could be. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 64
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Jeramie Wager | Environmental Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 64
Deficiencies: 0
Date: Dec 2, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to a report of alleged theft in the building.
Complaint Details
The complaint involved a resident reporting money stolen from their room on 11/13/2024. An investigation was conducted, staff were interviewed, and law enforcement was contacted but the resident declined to speak with them. Two other similar incidents were noted in the past 12 months with no findings.
Findings
The investigation found no staff witnessed the alleged theft, and the facility followed its theft policy and reported the incident as required. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during investigation and provided information about the alleged theft. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 40
Capacity: 64
Deficiencies: 1
Date: May 10, 2024
Visit Reason
The inspection visit was an unannounced continuation of the annual required inspection to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was found to have resident records containing all required documents, but some care plans did not address current ongoing issues. Staff training documentation was incomplete, specifically annual training records were missing, though First Aid and CPR certifications were current. Guidance was provided regarding activity program staffing and regulatory compliance.
Deficiencies (1)
Facility could not produce documentation of completed annual staff training, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Plan of Correction Due Date: May 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sonia Sandoval | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Bethany Moellers | Licensing Program Manager | Supervisor named in the report |
| Zenia Shah | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 64
Deficiencies: 0
Date: May 10, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not providing adequate care and supervision at Mountain View Assisted Living Facility.
Complaint Details
The complaint alleged inadequate care and supervision by staff. The investigation was unannounced and included interviews and record reviews. The allegation was unsubstantiated due to lack of evidence.
Findings
The Licensing Program Analyst found no evidence to support the allegation. Resident care plans were current, shower sheets were completed, call logs showed no long delays, and residents reported satisfaction with care. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 64
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Sonia Sandoval | Business Office Manager | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Capacity: 64
Deficiencies: 0
Date: May 7, 2024
Visit Reason
The visit was an unannounced Required-1 Year inspection conducted to evaluate the health and safety conditions of the Mountain View Assisted Living Facility.
Findings
The inspection found no immediate health, safety, or personal rights violations. The facility was clean, well-maintained, and properly equipped with required safety devices and supplies. Food storage and preparation appeared appropriate, and disaster drills were regularly conducted.
Report Facts
Food supply duration: 7
Food supply duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
The inspection was conducted as a complaint visit to follow up on an Unusual Incident Report regarding a resident who was observed leaving the facility without assistance on 04/05/2024.
Complaint Details
The complaint involved a resident (R1) who was seen walking to an activity and later found outside the facility. The facility's initial assessment did not list wandering behaviors, but after the incident, the care plan was updated. The complaint was not substantiated as no citations were issued.
Findings
The facility followed regulations by updating the resident's care plan and placing the resident on frequent checks after the incident. No citations were issued as a result of this incident.
Report Facts
Incident date: Apr 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint visit and follow-up on the unusual incident report |
| Zenia Shah | Administrator/Director | Facility administrator met during the inspection |
| Sonia Sandoval | Business Office Manager | Received telephone call regarding the resident incident |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 03/18/2024 regarding staff not safeguarding residents' personal belongings, not meeting dietary needs, not keeping the facility free from pests, and not being prepared for an emergency disaster.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found no supporting evidence to substantiate the allegations. The facility has policies and procedures in place for theft prevention, dietary needs, pest control, and emergency preparedness, and no violations were observed during the visit. Therefore, the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 64
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation |
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 14
Capacity: 14
Deficiencies: 0
Date: Apr 29, 2024
Visit Reason
An unannounced prelicensing visit was conducted due to a change of ownership with residents in care.
Findings
The facility was found to be in substantial compliance with all required paperwork, fire clearance, and safety measures, and appears ready for licensure pending final approval.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 4
Fire clearance capacity: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the unannounced prelicensing visit |
| Brittany Lockhard | Administrator | Facility Administrator met during inspection |
Inspection Report
Original Licensing
Census: 14
Capacity: 14
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The visit was conducted as part of the initial licensing process (CHOW application) for Mountain View Assisted Living Facility, including verification of applicant and administrator understanding of licensing laws and facility operation.
Findings
The applicant and administrator participated in a virtual interview confirming their understanding of community care facility licensing laws, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Lockhart | Licensee/Administrator | Participant in licensing interview and applicant verification |
| Corey Lockhart | Licensee | Participant in licensing interview and applicant verification |
| Darla Neeley | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation |
| Diamond Law | Licensing Program Analyst | Named as Licensing Program Analyst conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 64
Deficiencies: 0
Date: Nov 27, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted on 2023-11-07 regarding a resident reporting missing money.
Complaint Details
The complaint involved a resident reporting missing money. The investigation did not substantiate the allegation as no evidence was found.
Findings
The investigation, including interviews with staff, residents, and law enforcement notification, found no evidence that the money was taken as the resident's recall changed during the investigation. The facility followed regulations to ensure resident needs were met and no citations were issued.
Report Facts
Capacity: 64
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during investigation |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Census: 34
Capacity: 64
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The visit was an unannounced case management visit conducted by the Licensing Program Analyst to meet with the new Executive Director and discuss areas of concern and possible solutions following a previous complaint visit.
Findings
No citations were issued during this visit. The Licensing Program Analyst informed the new Executive Director about the previous complaint visit and requested documentation appointing her as the new Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zenia Shah | Executive Director | Met with Licensing Program Analyst during the case management visit. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the administrator was not providing written responses to the Resident Council.
Complaint Details
The complaint was substantiated. The allegation was that the administrator did not provide written responses to the Resident Council. The investigation confirmed this failure based on review of resident council minutes and interviews.
Findings
The investigation found that the administrator failed to respond in writing to the Resident Council's written concerns or recommendations, which is a second violation of the same regulation within a 12-month period. An immediate civil penalty of $250 was issued, and a plan of correction was requested.
Deficiencies (1)
Failure to respond in writing to Resident Council concerns or recommendations within 14 calendar days as required by regulation.
Report Facts
Civil penalty amount: 250
Plan of Correction due date: Aug 31, 2023
Facility capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation. |
| Alexandria Rodriguez | Executive Director | Met with Licensing Program Analyst during investigation. |
| Jeannette Kinney | Administrator | Named in the allegation for not providing written responses to Resident Council. |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 2
Date: Jun 20, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not respond to residents' call buttons in a timely manner and that the facility lacked adequate staffing to meet residents' needs.
Complaint Details
The complaint investigation was substantiated based on the preponderance of evidence standard. The allegations included untimely response to call buttons and inadequate staffing. The report was reviewed with the facility representative and appeal rights were given.
Findings
The investigation found substantiated evidence that several residents experienced call response times longer than 20 minutes, particularly during meal times when staff were serving meals. Staffing levels in the memory care section were insufficient to meet resident needs, though staffing has increased since mid-April.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, posing an immediate health, safety, or personal rights risk.
Facility did not have and maintain a current, written definitive plan of operation, as evidenced by delayed response times to call pendants used in emergencies, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 64
Response times over 20 minutes: 171
Estimated days for POC Type A: 1
Estimated days for POC Type B: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation report |
| Alexandria Rodriguez | Executive Director | Facility representative met during investigation and report review |
Inspection Report
Annual Inspection
Census: 34
Capacity: 64
Deficiencies: 2
Date: Jun 1, 2023
Visit Reason
The visit was an unannounced annual case management inspection to conduct remaining file reviews and observe facility operations as part of the required 1-year inspection started on 2023-05-08.
Findings
The inspection found deficiencies in personnel records where 5 of 5 staff files lacked documentation of current annual training or initial orientation. Additionally, there were insufficient food service personnel to meet resident needs, as only one person was observed preparing meals and only 9 of 20 residents had received their meal at the time of observation.
Deficiencies (2)
Personnel records did not contain verification of required staff training and orientation.
Insufficient food service personnel employed and scheduled to meet the needs of residents.
Report Facts
Staff files reviewed: 5
Staff files lacking training documentation: 5
Residents observed waiting for meals: 20
Residents served meal at time of observation: 9
Facility capacity: 64
Facility census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Executive Director | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Annual Inspection
Census: 35
Capacity: 64
Deficiencies: 0
Date: May 8, 2023
Visit Reason
An unannounced annual required inspection of the licensed senior care facility was conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean and in good repair with unobstructed walkways and exits. All required notices were posted visibly. Safety measures including secure toxins, appropriate water temperature, charged fire extinguishers, working smoke detectors, fire sprinklers, and carbon monoxide detectors were verified. Medication storage was secure and resident records reviewed were complete with current admission agreements and physician orders. No citations were issued during this visit.
Report Facts
Resident records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Administrator | Met with Licensing Program Analyst during the inspection. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 64
Deficiencies: 1
Date: Jan 27, 2023
Visit Reason
Unannounced visit/investigation of a complaint received on 2023-01-06 regarding the licensee and/or administrator not responding to the resident council per regulations.
Complaint Details
Complaint was substantiated. The allegation that the licensee and/or administrator is not responding to the resident council per regulations was found to be true based on investigation.
Findings
The Executive Director did not provide written responses to the resident council as required by regulation; responses were only given verbally at a town hall meeting. Facility policy did not address how to respond to the resident council. The allegation was substantiated based on the preponderance of evidence.
Deficiencies (1)
Failure to respond in writing to resident council concerns or recommendations within 14 calendar days as required by CCR §1569.157(c).
Report Facts
Capacity: 64
Census: 27
Plan of Correction Due Date: Feb 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Kinney | Executive Director | Named in findings for failure to respond in writing to resident council |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 64
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted on 12/28/2022 regarding a resident's un-witnessed fall.
Complaint Details
The visit was triggered by an incident report concerning a resident's fall. No citations or deficiencies were issued, indicating no substantiated violations.
Findings
The resident had an un-witnessed fall in their bedroom, complained of head pain, was taken to the hospital, and returned with no new instructions. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Kinney | Executive Director | Met with Licensing Program Analyst during the case management visit. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 64
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted regarding a resident's fall on 11/14/2022.
Complaint Details
The visit was triggered by an incident report concerning Resident 1's fall and injury. The complaint was investigated and found to be managed appropriately with no citations issued.
Findings
The resident fell while removing hearing aides, resulting in a fractured pelvis and subsequent hospitalization. Facility staff responded promptly and followed regulations to meet the resident's needs. No citations were issued.
Report Facts
Dialysis frequency: 3
Incident report submission date: Nov 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Kinney | Executive Director | Met with Licensing Program Analyst during the visit and involved in review of records related to the incident. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report regarding the unexpected death of a resident submitted on 10/20/2022.
Complaint Details
The visit was triggered by a complaint/incident report concerning an unexpected resident death. The complaint was investigated and found to be unsubstantiated as the facility followed proper protocol.
Findings
The Licensing Program Analyst reviewed resident records and interviewed staff, confirming that the facility followed proper protocol and regulations related to the incident. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Executive Director | Met with Licensing Program Analyst during the visit and involved in review of incident. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and reviewed records. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 33
Capacity: 64
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
Unannounced case management visit to follow up on areas of concern from previous visits.
Findings
The Licensing Program Analyst toured the facility, observed resident activities, and discussed courtyard use with the administrator. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Kinney | Administrator | Met with Licensing Program Analyst during the visit and discussed facility operations. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 35
Capacity: 64
Deficiencies: 0
Date: Aug 19, 2022
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted regarding an unexpected resident death.
Findings
The Licensing Program Analyst reviewed resident records and interviewed the Director, finding that the facility followed the resident care plan and regulations. Infection control procedures and visitation protocols were reviewed, and no citations were issued.
Report Facts
Capacity: 64
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Executive Director | Met with Licensing Program Analyst during the visit |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Bethany Moellers | Licensing Program Manager | Named in the report |
Inspection Report
Census: 36
Capacity: 64
Deficiencies: 0
Date: Jul 11, 2022
Visit Reason
Unannounced case management visit conducted in response to several incident reports submitted to Community Care Licensing.
Findings
The facility addressed incidents involving a resident's aggressive behavior and falls by consulting the physician, notifying responsible parties, scheduling additional staff, and updating care plans. A reported suspected elder abuse incident was investigated with law enforcement involvement, but the resident did not confirm the report or seek hospital care. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Executive Director | Met with Licensing Program Analyst during the visit and involved in incident management. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 33
Capacity: 64
Deficiencies: 0
Date: Jun 21, 2022
Visit Reason
An unannounced annual required infection control inspection was conducted to evaluate the Infection Control procedures and practices of the Mountain View Assisted Living Facility.
Findings
The facility was found to be clean, with proper infection control measures in place including PPE supplies, a Covid Mitigation plan, and secure medication storage. No deficiencies or citations were found during the inspection.
Report Facts
Facility capacity: 64
Resident census: 33
Inspection duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Executive Director | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 2
Date: May 5, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including inadequate staffing, resident urinary tract infections, unmet toileting and showering needs, residents left in soiled clothing, and delayed response to call buttons.
Complaint Details
The complaint investigation was substantiated for allegations of inadequate staffing, unmet resident needs including toileting, bathing, and call button response delays, and residents left in soiled clothing. The allegation of medication mismanagement was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated that the facility did not have adequate staffing to meet resident needs, resulting in delayed assistance with toileting, bathing, and call button responses, causing some residents to sustain urinary tract infections and be left in soiled clothing for extended periods. One allegation regarding medication mismanagement was found unsubstantiated due to lack of evidence.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, posing an immediate health and safety risk.
Facility failed to provide care, supervision, and services that meet individual resident needs, including assistance with showering, toileting, and daily care, posing immediate health, safety, and personal rights risks.
Report Facts
Capacity: 64
Census: 37
Deficiency count: 2
Plan of Correction due date: May 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Administrator / Executive Director | Met with Licensing Program Analyst during investigation and named in findings related to staffing and care deficiencies |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 5
Date: May 5, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2022-03-22 regarding personal rights violations, lack of supervision, facility disrepair, lack of personal accommodations and services, and failure to report incidents.
Complaint Details
Complaint investigation was substantiated based on preponderance of evidence. Allegations included personal rights violations, lack of supervision, facility disrepair, lack of personal accommodations and services, and failure to report incidents.
Findings
The investigation substantiated multiple allegations including violations of residents' personal rights such as placing continent residents in adult diapers instead of prompting toileting, lack of supervision resulting in a resident being left on a toilet for an extended period, facility disrepair with worn furniture and mold presence, lack of disposable towels in shared restrooms, and failure to report several resident falls resulting in emergency visits.
Deficiencies (5)
Staff placed adult diapers on a continent resident and failed to assist timely with toileting needs, violating personal rights.
Facility staff insufficiently supervised residents, resulting in a resident being left on a toilet for an extended period.
Memory care dining furniture was worn to the point sanitation was not possible, posing health and safety risks.
Shared resident restrooms lacked disposable towels, posing a potential health risk.
Facility failed to report several resident falls resulting in injury to responsible parties and CCLD.
Report Facts
Capacity: 64
Census: 37
Deficiency count: 5
Plan of Correction due dates: May 6, 2022
Plan of Correction due dates: May 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation report |
| Angie Smith | Executive Director | Facility administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 2
Date: May 5, 2022
Visit Reason
The visit was conducted as a complaint investigation to review hospice documentation and assess compliance with care plans and activity schedules.
Complaint Details
The visit was complaint-related, with violations observed during the investigation. Substantiation status is not explicitly stated.
Findings
The Licensing Program Analyst observed violations including failure to follow a hospice care plan requiring two staff during bathing assistance and lack of scheduled activities due to staffing shortages. Deficiencies were cited related to hospice care and planned activities.
Deficiencies (2)
Licensee did not follow a hospice care plan requiring two staff to assist residents during bathing, posing a potential health or safety risk.
Activities scheduled during March and April were not conducted as scheduled or in an engaging manner due to lack of staff, posing a potential health risk.
Report Facts
Capacity: 64
Census: 37
Plan of Correction Due Date: May 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Administrator | Facility administrator met during inspection and reviewed report |
| Christopher Arnhold | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 29
Capacity: 64
Deficiencies: 0
Date: Feb 1, 2022
Visit Reason
The visit was an unannounced case management visit to review a concern regarding the facility raising care service rates concurrently with the annual rate increase.
Findings
The Licensing Program Analyst reviewed the notices sent to residents and families and found they met the required 60-day timeline for rate increases. No citations were issued during this visit.
Report Facts
Rate increase notice date: Oct 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Whitney Rodriguez | Health Services Director | Met with Licensing Program Analyst during case management visit |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 2
Date: Dec 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including falsifying logs, inadequate activities, failure to follow resident care plans, multiple resident falls, unexplained injuries, medication errors, COVID-19 screening failures, unsanitary kitchen practices, untimely meal service, and unsafe buildings and grounds.
Complaint Details
The complaint investigation was substantiated for allegations regarding inadequate activities and failure to follow resident care plans, specifically related to medical care and activity participation. Other allegations including falsifying logs, resident falls, medication errors, COVID-19 screening, kitchen sanitation, meal service, and building safety were unsubstantiated or unfounded.
Findings
The investigation substantiated deficiencies related to inadequate activities and failure to ensure medical care was provided as ordered, posing health and personal rights risks to residents. Other allegations such as falsifying logs, resident falls, medication administration, COVID-19 screening, kitchen sanitation, meal timeliness, and building safety were found unsubstantiated or unfounded.
Deficiencies (2)
Licensee did not ensure a resident received appropriate medical care as ordered for a wound, posing an immediate health risk.
Licensee did not ensure residents were encouraged to contribute to the planning and feedback of activities, posing a potential personal rights risk.
Report Facts
Facility capacity: 64
Plan of Correction due date: Dec 13, 2021
Plan of Correction due date: Dec 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Frances King | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Angie Smith | Administrator | Facility administrator named in the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 64
Deficiencies: 0
Date: Oct 21, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff yelled at a resident in care.
Complaint Details
The allegation that staff yelled at a resident was investigated and found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found no supporting evidence that staff yelled at a resident. Interviews with staff and residents, and review of records, did not substantiate the allegation, which was therefore deemed unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the complaint investigation. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 1
Date: Sep 2, 2021
Visit Reason
The visit was an unannounced case management inspection conducted due to a medication error that occurred on 2021-08-26, where a staff member administered the wrong medication to a resident.
Complaint Details
The visit was complaint-related due to a medication error. Notifications were made to the licensing agency, physician, and family. An internal investigation was completed and provided to the licensing analyst.
Findings
The investigation confirmed that a resident was given medication prescribed to a different resident, posing an immediate health risk. The staff member involved received additional training, and the facility requested further training for all medication staff through the pharmacy.
Deficiencies (1)
The licensee did not ensure a resident was assisted appropriately with medications and was given medication prescribed to a different resident, posing an immediate health risk.
Report Facts
Total licensed capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angie Smith | Executive Director | Met with Licensing Program Analyst during the visit and requested additional training for medication staff |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 31
Capacity: 64
Deficiencies: 0
Date: Jun 3, 2021
Visit Reason
The inspection was an unannounced Annual Required infection control inspection focusing on the Infection Control procedures and practices of the Mountain View Assisted Living Facility.
Findings
The facility was found to be clean, with all exits free from obstruction, and proper storage of toxins and medications. PPE supplies and COVID mitigation plans were in place, and no deficiencies or citations were found during the inspection.
Report Facts
Capacity: 64
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Kesler | Administrator | Met with Licensing Program Analysts during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
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