Mountain Manor Senior Residence

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Type of visit: Required - 1 Year

On 7/22/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPA met with staff and explained the purpose of the visit. Administrator Kim Jackson came after short while and assisted with today's visit. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, bathrooms, dining room, common areas, storage area, and laundry area. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 115 degrees Fahrenheit , which is within the required range of 105 to 120 degrees. The temperature in the facility was 73-74 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in common areas which were ready for emergency use. LPA reviewed fire and disaster drill logs, which are conducted quarterly. LPA observed required Licensing posters posted throughout the facility. LPA conducted a file review of five (5) staff and five (5) residents records. Residents and staff records were found to be complete. Medications are centrally stored, locked, and were inaccessible to residents. No deficiencies were observed or cited from this inspection per Title 22 Regulations. Exit interview was conducted and copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jul 22, 2026

Type of visit: Case Management - Incident

On August 4, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived unannounced at the facility to conduct a case management visit regarding an incident report the department received via fax on 7/15/25. LPAs met with Administrator, Darrell Price and explained the purpose of the visit. The incident occurred on 07/15/25, after dinner, between R1 and R2 in the common area. Facility notified both resident's responsible party, physician and other required parties regarding this incident. As a result of the incident, no deficiencies cited. Exit interview conducted, a copy of the report provided to facility staff. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Required - 1 Year

On 08/04/25, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPAs met with Administrator Darrell Price and explained the purpose of the visit. LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, bathrooms, dining room, common areas, storage area, and laundry area. LPAs observed required furniture, and lighting throughout the residents' bedrooms and facility. LPAs observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 107 degrees Fahrenheit in a residents bathroom, which is within the required range of 105 to 120 degrees. The temperature in the facility was 74 degrees. First aid kit was completed. LPAs observed fire detectors and carbon monoxide detectors to be operable. LPAs observed the fire extinguisher, located in common areas which were last inspected on 02/28/25. LPAs reviewed fire and disaster drill logs, which are conducted quarterly. LPAs observed required Licensing posters posted throughout the facility. LPAs conducted a file review of five (5) personnel and five (5) residents records. Both personnel and resident records are incomplete. Medications are centrally stored, locked, and were inaccessible to residents. No deficiencies are being observed or cited during today's inspection per Title 22 regulations. Exit interview conducted and copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Case Management - Incident

On 05/22/25, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 05/13/25. LPA met with Administrator, Darrel Price and explained the purpose of the visit. The incident occurred on 05/11/25 at approximately 9:30 AM when facility staff observed resident, R1 to be missing during rounds. Facility staff searched in the facility but was not successful. R1 returned around 11:30 AM and told staff that they went to church without notifying anyone at the facility with their roommate. Based on R1's ,LIC 602 Physician's Report, signed on 11/06/24 indicated that R1 was deemed unable to leave the facility unassisted. Record review indicated that R1 was residing at the facility since 05/03/24 and were on staff check list for hourly monitor prior to this incident. Staff stated that facility has increased R1’s safety check every 30 minutes/daytime and every hour /night time to ensure R1s health and safety after this incident. Facility notified R1s responsible party, physician and other required parties regarding this incident. LPA and administrator discussed having the appropriate number of staff to ensure the care and supervision of residents in care are being met. As a result of the incident, deficiencies cited. Please see LIC 809-D, per Title 22 Regulations. Exit interview conducted, a copy of the report and appeal rights provided to facility staff. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 23, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Based on file review, Licensee did not comply with the section cited above as R1 was observed by a facility staff to be leaving the facility unassisted on 05/11/25 when R1's LIC 602 stated R1 cannot leave facility unassisted which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee is to submit a plan of how facility will ensure residents' care and supervision are met and shall conduct staff training. Plan of Correction is to be sent to CCLD by 05/23/25.

Allegation investigated: Staff inappropriately spoke to resident in care.

Licensed Program Analyst (LPA) Cassandra Mikkelson and Licensed Program Manager (LPM) Laura Munoz arrived at the facility to conduct a complaint investigation. LPA and LPM met with Executive Director Darrell Price and explained the purpose of today's visit. This property is divided into (2) two sections. The assisted living (AL) section is licensed by CCL and the skilled nursing (SN) section is licensed by Department of Public Health. Mr. Price provided a resident roster to LPA and LPM. Based on the resident roster, the resident who is the subject to this complaint resides on in SN. Staff are not shared between AL and SN of the facility. Based on interviews conducted and records reviewed, the allegation that staff inapproriately spoke to residents in care did not occur in AL therefore the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Administrator. A copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jan 17, 2025 · control 59-AS-20250110164045

Type of visit: Case Management - Incident

On 10/24/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a SOC 341 the Department received. LPA met with Resident Care Director and explained the purpose of the visit. The incident occurred on 10/7/2024 when R1 had an unwitnessed fall and was transported by medical services to the emergency room for an assessment. It was then at the emergency room when R1 alleged "sexual assault by adult". Police report was additionally filed by the hospital. Facility was not notified until facility observed the following on R1's discharged paperwork. LPA and Resident Care Director discussed that roughly on the same time, R1 had urinary tract infection (UTI) then an unwitnessed fall which R1 then alleged the following accusation. Resident Care Director stated based on R1's history, R1's confusion increase when R1 has UTI. Resident Care Director stated that based on conversation with R1's responsible party, R1 has the tendency to talk about sexual assault when in the state of confusion. Resident Care Director stated R1 has chronic UTI's prior to admission, which R1 has been on cranberry supplements. Additionally, Resident Care Director stated there are no male caregivers at the facility. Facility is licensed for 32 ambulatory and 1 non ambulatory residents, Resident Care Director stated only one resident in care has dementia. Resident Care Director stated due to current census, staff has been providing residents in care with frequent hourly routine checks to ensure health and safety. At this time, LPA requested a copy of R1's hospital discharge paperwork, medication list, LIC 602 and LIC601/ID/Emergency Contact. The following incident remains under review by the Department until notified otherwise. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Required - 1 Year

On 07/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Med Tech and explained the purpose of the visit, who then contacted Residential Care Director who arrived to the facility shortly afterwards. Census is one (1) non-ambulatory resident, 10 ambulatory residents, and zero residents on hospice services. Facility is licensed for 1 non-ambulatory, 32 ambulatory residents, hospice waiver of 1. During today's visit, LPA and Residential Care Director conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: dining room, medication room, five residents room and the common areas. LPA observed kitchen to be fully staffed with cooks, where residents are unable to enter to access sharps. Laundry room is kept locked at all times. LPA observed medication carts to be locked and inaccessible to residents in care. LPA conducted a random medication count for four residents in care. LPA observed medications to be accounted for. File review was conducted for five residents files and five personnel files. LPA observed the required documents present in file. Additionally, LPA provided facility a copy of §1569.625 Staff training; legislative findings; contents and §1569.312 Basic services requirements. LPA and Residential Care Coordinator discussed conservatorship of R1. LPA advised facility to keep documentation of facility attempts and contacting county judge if needed. Residential Care Coordinator reported no additional concerns at the moment. At this time, LPA is requesting a copy of facility liability insurance and LIC 500 by Monday July 22, 2024. No deficiencies observed. Exit interview and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2024

Type of visit: Case Management - Incident

On 5/8/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 5/6/2024. LPA met with Med Tech, and explained the purpose of the visit. During today's visit, Administrator and Residential Care Director was unavailable. LPA spoke with Residential Care Director via telephone during LPA's visit to conduct interview and explain the purpose of the visit. The incident occurred on 5/5/2024 at approximately 1:30 PM when facility staff observed R1 to be missing during rounds. Facility staff then contacted Residential Care Director, who then found R1 "a few blocks from facility" with alcohol and was observed to be impaired beyond baseline. Based on R1's LIC 602 Physician's Report, signed on 2/18/2024, indicated that R1 was deemed unable to leave the facility unassisted. LPA and Residential Care Director discussed having the appropriate number of staff to ensure the care and supervision of residents in care are being met. Additionally, LPA and Residential Care Director discussed this incident may have been a new placement trauma which caused R1 to flight. Residential Care Director stated a conference call be made to elaborate the reasoning why R1 is unable to leave facility unassisted. As a result of the incident, deficiencies cited. Please see LIC 809-D, per Title 22 Regulations. Exit interview conducted, a copy of the report and appeal rights provided to facility staff. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 9, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Based on file review, Licensee did not comply with the section cited above as R1 was observed by a facility staff to be leaving the facility unassisted when R1's LIC 602 stated R1 cannot leave facility unassisted which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee is to submit a plan of how facility will ensure residents' care and supervision are met. Plan of Correction is to be faxed to CCLD by 5/9/2023.