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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003016
Report Date: 12/11/2023
Date Signed: 12/11/2023 01:53:14 PM


Document Has Been Signed on 12/11/2023 01:53 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: 17DATE:
12/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Chad BoeddekerTIME COMPLETED:
02:30 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 on Monday December 11, 2023 to complete an unannounced prelicensing visit.

LPA toured the facility with Administrator Chad. Previous prelicensing visits were conducted on 10/19/2023 and 10/26/2023. During todays visit, there were no health or safety violations observed.

This facility has been approved for a secured perimeter by the South Placer Fire Protection District (inspection date 11/14/2023).

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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