<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003016
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:52:34 PM


Document Has Been Signed on 10/19/2023 12:52 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:
315003016
ADMINISTRATOR:DUNHAM, JOSEPHFACILITY TYPE:
740
ADDRESS:3400 CHISOM TRAILTELEPHONE:
(916) 652-8000
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:27CENSUS: 22DATE:
10/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Chad BoeddekerTIME COMPLETED:
12:00 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
Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday October 19, 2023 to conduct a prelicensing inspection. This application is a change in ownership with residents in care.

During today's prelicensing inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed 7 resident files. All resident files contained the required paperwork.

LPA conducted an inspection of the facility to ensure compliance with Title 22 regulations. Facility inspection was completed in the following areas: resident apartments, resident bathrooms, common area shower rooms, kitchen, staff apartments, garages, and backyard.

Applicant has NOT satisfied all requirements in accordance to Title 22, California Code of Regulations due to the following: non-skid mats were not observed in all resident showers, incomplete first aid kit, and no safety measures in resident apartments to address behaviors such as ingestion of toxic materials.

The Administrator stated that the facility will be in full compliance by 10/26/2023. LPA will conduct a follow-up visit at a later date.

Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) that facility did not meet all the pre-licensing components yet. A copy of this report was provided to the facility. Exit interview conducted.

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.

LIC809 (FAS) - (06/04)
Page: 1 of 1