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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003016
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:04:30 PM


Document Has Been Signed on 10/26/2023 12:04 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: 21DATE:
10/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Chad BoeddekerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday October 26, 2023 to continue the prelicensing inspection. This application is a change in ownership with residents in care.

Applicant has fixed the previous issues: non-skid mats 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. LPA observed a complete first aid kit, non-skid mats in shower rooms, and locks on bathroom cabinets to secure personal hygiene and grooming supplies.

LPA observed the facility to have a secured perimeter which the recent fire inspection clearance does not show approval. LPA obtained a waiver letter requesting for a secured perimeter from the Administrator. If approved, the Department will request a fire inspection to be conducted.

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: 10/26/2023
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.

LIC809 (FAS) - (06/04)
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