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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002345
Report Date: 11/17/2023
Date Signed: 11/17/2023 02:52:28 PM


Document Has Been Signed on 11/17/2023 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LOOMISFACILITY NUMBER:
315002345
ADMINISTRATOR:CHAD BOEDDEKERFACILITY TYPE:
740
ADDRESS:3400 CHISOM TRAILTELEPHONE:
(916) 652-8000
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:27CENSUS: 20DATE:
11/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Chad BoeddekerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived at the facility on Friday November 17, 2023 to follow up on an incident reported to the Department on Monday November 13, 2023.

LPA discussed the incident with Administrator. LPA reviewed R1's file. LPA obtained copies of R1's physician reports (2), care plans (2), LIC601, updated resident assessment, and updated needs and services plan.

LPA interviewed S1 and S2 regarding R1's behavior.

Administrator and LPA discussed implementing 1:1 when R1 returns from the hospital. LPA obtained a copy of the 30 day notice to evict for R1.

LPA discussed the incident with Evelyn Mendez-Choy, Regional Vice President of Operations.

No deficiencies cited. Exit interview conducted. 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: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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