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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002345
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:48:29 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
09/12/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230912141758
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: 24DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Damion Anderson, Regional Wellness DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not properly storing residents’ medication
INVESTIGATION FINDINGS:
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LPA Parks arrived on Thursday September 14, 2023 to open a complaint investigation regarding the above allegation.

LPA discussed the allegations with Regional Wellness Director Damion Anderson. LPA toured the kitchen with Regional Wellness Director and kitchen staff David. LPA observed resident medication in the kitchen refrigerator (pictures taken). Per staff interviews, the kitchen is not locked and therefore accessible to residents. Additionally, the facility does not have a refrigerator for resident medication.

Based on the information detailed above, LPA finds that the allegation is 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.
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: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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 2
Control Number 59-AS-20230912141758
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: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2023
Section Cited
CCR
87465(h)(2)
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Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place . . . This requirement is not met as evidenced by:
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Regional Wellness Diretor destroyed medication (which was discontinued). Citiation is cleared during visit. Licensee will provide a refrigerator for the medication room.
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Based on observation, the licensee did not comply with the section cited above by storing resident medication in kitchen refrigerator, which poses an immediate health, safety or personal rights risk to persons 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: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2