315003016-3-17-2026-59-AS-LMUZ-DSBTJ8-20260319144555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315003016
Report Date: 03/17/2026
Date Signed: 03/17/2026 10:30:43 AM

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
10/06/2025 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20251006123021

FACILITY NAME:	SENIOR CARE VILLA OF LOOMIS		FACILITY NUMBER:	315003016
ADMINISTRATOR:	ILONA CORPUS		FACILITY TYPE:	740
ADDRESS:	3400 CHISOM TRAIL		TELEPHONE:	(916) 652-8000
CITY:	LOOMIS	STATE: CA	ZIP CODE:	95650
CAPACITY:	35	CENSUS: 22	DATE:	03/17/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shreetika Chand		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday March 17, 2026, to deliver findings for a complaint received on 10/6/2025. LPA met with Administrator Shreetika and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and obtained documentation pertinent to the investigation. The following timeline of events is as follows: on 10/3/2025 at approximately 3:00 am, R1 entered the apartment of R2. R2 attempted to escort R1 out of their apartment when an unwitnessed altercation occurred. R1 was transported to the hospital and diagnosed with an acute chronic left front subdural hematoma, right lateral clavicle fracture, and multiple right-sided rib fractures. R2 was also transported to the hospital and diagnosed with a laceration to their hand and leg.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20251006123021

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: 315003016
	VISIT DATE: 03/17/2026

NARRATIVE

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Staff interviews revealed that on the night of the incident, there were only two staff working. According to staff and Administrator interviews, there should have been three staff on NOC shift. According to the October staffing schedule, the NOC shift schedule was not consistently staffed with 3 employees. Per the Administrator, a full-time NOC shift employee had recently reduced their hours due to personal reasons. Interviews described R1 as having a tendency of wandering exit seeking behavior, and aggression towards staff and other residents. Although there was no previous incident of physical attacks from R1 to other residents, staff noted it was only a matter of time that R1 attacked a resident due to their aggression. According to R1’s needs and services plan, they required total assistance with interventions due to agitation and aggressiveness to ensure the safety of other residents. Additionally, R1 was identified as frequently exit seeking. R1’s physicians report lists R1’s primary diagnosis as Dementia with agitation and aggressive behaviors. Due to the facility’s inadequate staffing, staff on site could not properly supervise the residents which resulted in an altercation between two residents.

Based on interviews conducted and documentation obtained, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. As a result of the resident's serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 is being assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.

See 9099-D for citation

Exit interview conducted. A copy of the report and appeal rights provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20251006123021

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: 315003016
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/18/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement is not met as evidenced by based on documentation reviewed and interviews conducted, the facility did not ensure staff were sufficient in number to	1 2 3 4 5 6 7	The facility agrees to: submit a plan for the facility to maintain adequate staffing in the event of staff quitting, call offs, no shows, etc.
	8 9 10 11 12 13 14	provide care and supervision to residents, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC9099 (FAS) - (06/04)

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