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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002345
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:25:03 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: 21DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Chad BoeddekerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff mistreated Resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday October 26, 2023, to complete and deliver findings to a complaint received on 9/12/2023. 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 R1’s file including nursing notes. LPA completed a walkthrough of the facility including the kitchen and resident apartments. The result of the investigation is as follows:

LPA learned that R1 was a previous resident at this facility. R1 was diagnosed with Lewy Body and had a history of behaviors. LPA learned that on 8/19/2023, S1 was witnessed throwing water on R1 while R1 was being aggressive. LPA learned that once the incident occurred, staff filled out an incident report and handed it to the previous Administrator.
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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 5
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
VISIT DATE: 10/26/2023
NARRATIVE
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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.

Deficiency 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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
CCR
87468(1)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights . . . (3) To be free from punishment, humiliation, intimidation, . . . This requirement was not met as evidenced by staff interviews which acknowledged that
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While at the facility, administrator submitted an all-staff meeting schduled for November 15, 2023 to train all staff regarding personal rights.
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S1 threw liquid on R1. This poses a direct threat to the health and safety of 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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 21DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Chad BoeddekerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff do not provide adequate food service for residents.
The facility has mold.
Facility kitchen equipment is in disrepair.
Staff are preparing resident meals in an unsanitary manner.
Staff do not ensure that residents’ mobility needs are met.
Staff are not ensuring that the facility is free of pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday October 26, 2023, to complete and deliver findings to a complaint received on 9/12/2023. 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 R2’s file. LPA conducted a kitchen walkthrough during two separate facility visits. The result of the investigation is as follows:

LPA reviewed medication orders for R2. Per staff interviews, R2 was served a regular diet prior and now has orders for a modified diet. Staff could not recall the date which R2’s diet was changed. LPA reviewed R2’s file and found the following: R2 had orders for a regular diet as of 8/6/2023. R2 was to begin a pureed diet on 9/5/2023. On 10/6/2023, R2 was prescribed a mechanical soft diet with thickened liquid. On 10/19/2023, LPA verified that R2 was being served a mechanical soft diet with thickened liquids. Based on staff interviews, LPA could not determine when staff began to serve R2 their modified diet.
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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 5
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
VISIT DATE: 10/26/2023
NARRATIVE
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LPA conducted a kitchen walk-through on 9/14/2023 and 10/19/2023, LPA did not observe mold in the kitchen during either visit. LPA observed the facility equipment to be operational. LPA and the Administrator discussed the plans to update the kitchen and its appliances.

LPA interviewed staff who stated that they wash their hands prior to serving residents their food. LPA observed a sink with soap in the dining room. Additionally, staff stated that they change their gloves when transitioning from resident care to serving meals.

LPA interviewed staff who stated that residents primarily spend time in the common area. Some residents prefer to be in their apartments. Residents are moved when staff assist with care and mealtimes. Residents are allowed to move about the facility if desired.

Based on staff interviews, the facility previously had issues with cockroaches (at the beginning of the year). According to staff, the Administrator at the time would call for pest control once a cockroach sighting was reported. Staff Staff stated that there have not been pest sightings in resident apartments. Administrator submitted proof of pest control services.

Based on information obtained during the investigation, LPA finds the allegations 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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5