315002345-10-14-2021-25-AS-SKEG-C7SUG7-20211014153353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002345
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:34:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	SENIOR CARE VILLA OF LOOMIS		FACILITY NUMBER:	315002345
ADMINISTRATOR:	ROXANA BUCURENCIU		FACILITY TYPE:	740
ADDRESS:	3400 CHISOM TRAIL		TELEPHONE:	(916) 652-8000
CITY:	LOOMIS	STATE: CA	ZIP CODE:	95650
CAPACITY:	27	CENSUS: 26	DATE:	10/14/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Roxana Bucurenciu		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On October 14, 2021, a Non-Compliance Conference was conducted on this day in the Sacramento North Regional Office via Microsoft Teams, due to COVID 19 precautions. The purpose of this Non-Compliance Conference meeting was to discuss the citations that has been issued in the last three years and complaint substantiated on July 30, 2021. Present in the meeting was Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Troy Ordonez, LPM Laura Munoz, Licensing Program Analyst (LPA) Sarena Keosavang, LPA Jacob Williams, Administrator/CEO Roxana Bucurenciu, and Caregiver Mary Bucurenciu. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. In the last three years, Senior Care Villa of Loomis, has been issued two type A and two type B deficiencies. The facility was cited for the following issues fire safety, incomplete records, not seeking timely medical care and false claims. Issues discussed during the meeting were: Complaint filed against this facility Incidental Medical and Dental Care Services/Observation of Resident Incomplete records/ Incomplete resident files Training-Pressure injuries False Claims Administrator Qualifications and Duties/Accountability Infectious Control Training for when to call 911 Continue on LIC 809-C Page 2

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SENIOR CARE VILLA OF LOOMIS	FACILITY NUMBER: 315002345
	VISIT DATE: 10/14/2021

NARRATIVE

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The facility has stated they will do the following to achieve continued and substantial compliance:

Incidental Medical and Dental Services
· Licensee shall develop and implemented Daily Skin Integrity Logs for any residents with wounds and or pressure injuries. Staff shall be trained on how and when to check the resident’s skin.
Prohibited Health Conditions
· Licensee shall not accept individuals with a stage 3 or 4 wounds, without an approved exception from the department or receiving hospice services. If current resident develops pressure wound(s), the licensee shall monitor wounds closely and ensure care is provided in accordance to the Physician’s Orders. If the pressure wounds become stage 3 or stage 4 pressure wounds, the licensee will transport the resident to a higher level of care immediately.
Reporting requirement
· Licensee stated facility staff will follow Title 22 reporting requirement

The Department requests licensee to submit the following by: 10/28/2021

A plan on how facility staff will be trained in observation of residents and when to call 9-1-1

Plan should include - responsibility will be to conduct training, monitor training and document training.

Develop daily charting notes and as well as shift change notes and ensure all staff are trained to utilize implemented charting system
A LIC308 with Administrator designee for all shifts shall be submitted
A LIC309 Administrative Organization
LIC 500 Personnel Report
A copy of Administrator's Certificate
Send in copies of needs and services plan for all residents in care.

CCLD will do the following:

Increase Monitoring

The Department would like the facility to submit the following by: 10/28/2021
A plan on how facility staff will be trained in required areas prior to completing duties.
Plan should include - responsibility will be to conduct training, monitor training and document training.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. An exit interview was conducted with Administrator Roxana Bucurenciu. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. Administrator Roxana Bucurenciu will sign the document and send signed copy to LPA, Sarena Keosavang at sarena.keosavang@dss.ca.gov.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

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