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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002345
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:05:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230918143353
FACILITY NAME:SENIOR CARE VILLA OF LOOMISFACILITY NUMBER:
315002345
ADMINISTRATOR:JOSEF DUNHAMFACILITY TYPE:
740
ADDRESS:3400 CHISOM TRAILTELEPHONE:
(916) 652-8000
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:27CENSUS: 22DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Chad BoeddekerTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Licensee does not ensure staff are adequately trained.
Facility staff left a resident outside for an unspecified amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday October 1, 2023, to complete and deliver findings to a complaint received on 9/18/2023. LPA met with Administrator Chad and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed med tech training records. Additionally, LPA reviewed R1’s file including an internal incident report. The result of the investigation is as follows:

LPA reviewed medication training for NOC shift med techs. LPA learned that all training is to be conducted through an online training platform, Relias. LPA noted that S1 had insufficient training of only 10.50 hours upon hire. S2 also had insufficient training of only 1.75 hours. Additionally, staff interviews revealed that staff are often put on the schedule to work independently prior to receiving new hire training, per regulations.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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
Control Number 59-AS-20230918143353
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SENIOR CARE VILLA OF LOOMIS
FACILITY NUMBER: 315002345
VISIT DATE: 10/19/2023
NARRATIVE
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LPA learned that on September 9, 2023, R1 was discovered on the back balcony by staff. Per staff interviews, R1 had not been seen by second shift until the time of discovery. Staff interviews stated that they were told that R1 was out with their son. Upon further investigation, staff learned that this was misinformation. Facility staff began to search for R1 when they were discovered at 3:45pm on the back balcony. Interviews also acknowledged that at this time, there were no alarms on doors to the outside. Alarms were subsequently installed after this incident.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20230918143353
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SENIOR CARE VILLA OF LOOMIS
FACILITY NUMBER: 315002345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by staff interviews which acknowledged that
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Facility has since installed auditory alarms on all doors. Administrator to submit a plan to LPA regarding testing doors to ensure alarm is working.
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the facility did not have audible alarms on the doors at the time R1 was discovered on the back patio. This poses a direct threat to the residents in care.
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Type B
11/17/2023
Section Cited
HSC
1569.69(a)(1)
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§1569.69 Employees assisting residents with self-administration of medication; training requirements
(1) . . the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, . . and 8 hours of other training or instruction
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Administrator to review training plan with corporate. Administrator to submit proof of training records for medication staff.
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This requirement was not met as evidenced by incomplete medication training prior to working independently. This poses an indirect threat to the residents 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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2023 and conducted by Evaluator Melissa Parks
COMPLAINT CONTROL NUMBER: 59-AS-20230918143353

FACILITY NAME:SENIOR CARE VILLA OF LOOMISFACILITY NUMBER:
315002345
ADMINISTRATOR:JOSEF DUNHAMFACILITY TYPE:
740
ADDRESS:3400 CHISOM TRAILTELEPHONE:
(916) 652-8000
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:27CENSUS: 22DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Chad BoeddekerTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff hit resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday October 18, 2023, to complete and deliver findings to a complaint received on 9/18/2023. LPA met with Administrator Chad and explained the purpose of the visit.

This is a repeat allegation. This allegation is being investigated under complaint control number 59-AS-20230912141758 received on 9/12/2023 under the allegation of ‘staff mistreated resident in care’. Therefore, LPA has determined that this allegation is unfounded as not to create a duplicate.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. A copy of this report was emailed to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4