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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003016
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:25:03 PM


Document Has Been Signed on 03/12/2024 03:25 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:ILONA CORPUSFACILITY TYPE:
740
ADDRESS:3400 CHISOM TRAILTELEPHONE:
(916) 652-8000
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:27CENSUS: 16DATE:
03/12/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ilona CorpusTIME COMPLETED:
03:30 PM
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On Tuesday March 12, 2024, Licensing Program Analyst Melissa Parks arrived to conduct an unannounced post licensing inspection.

During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed 4 resident and 2 staff files.

LPA toured the facility with Administrator Ilona. Due to a planned power outage, LPA will return to the facility at a later date to finish the post licensing visit.

No deficiencies cited. An exit interview conducted. A copy of this report was emailed.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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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