315003016-7-11-2024-59-AS-MSEY-D79KZA-20240717082022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315003016
Report Date: 07/11/2024
Date Signed: 07/11/2024 10:38:55 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
06/19/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240619163711

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:	27	CENSUS: 15	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ilona Corpus		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff does not ensure facility is free of pests
Staff does not ensure kitchen is clean and sanitized

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday July 11, 2024, to complete and deliver findings to a complaint received on 6/18/2024. LPA met with Administrator Ilona and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator and staff regarding the allegations. LPA toured the kitchen and observed the following: evidence of pests in pest glue traps and baby pests on kitchen shelf. Food particles were observed on the floor and kitchen shelves. The kitchen floor was observed to be dirty. Kitchen refrigerator shelves were observed to be dirty. LPA photographed the items detailed above.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Appeal rights were given.
Exit interview conducted. A copy of this report was left at the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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-20240619163711

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: 07/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/25/2024 Section Cited CCR 8755(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply:(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.	1 2 3 4 5 6 7	Administrator to send LPA pictures of deep cleaned kitchen and copy of pest control records.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by uncleanliness and pests in kitchen. This poses an indirect threat to the health and safety of 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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/19/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240619163711

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:	27	CENSUS: 15	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ilona Corpus		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff does not provide adequate supervision resulting in resident wandering away from facility
Staff does not provide adequate food service to residents
Staff does not have adequate staffing
Staff does not meet training requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday July 11, 2024, to complete and deliver findings to a complaint received on 6/18/2024. LPA met with Administrator Ilona and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed staff training records and staff schedules. LPA reviewed the facility file for R1. The result of the investigation is as follows:

LPA interviewed staff regarding R1. LPA learned the following: R1 moved into the community at the end of May. On June 1st, R1 was observed in the parking lot. Upon investigation, the facility learned that construction crew did not lock a gate. The facility immediately locked the gate, spoke with all construction crea and installed cameras. LPA determined that the resident was on facility property, therefore this was not an elopement and the facility followed proper protocol.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240619163711

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: 07/11/2024

NARRATIVE

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LPA learned that R2 requires staff to assist them with all meals. R2 is on a pureed diet. Through staff interviews, LPA learned that R2 is assigned staff who will assist with feeding once the residents in the dining room have their food. LPA learned there is another resident on a modified diet, but they eat their meal in the dining room. No staff interviews acknowledged that R2 eats their meals outside of the facility’s designated mealtimes. Staff interviews also did not reveal that R2 has missed any meals (other than when R2 has refused meals/food).

Staff interviews acknowledged that there are always two staff on the NOC (overnight) shift. No interviews revealed that facility has only one employee working at night. LPA reviewed staff training documents for the previous 3 hires: activities assistant, caregiver, and kitchen employee. Staff training documents show that staff complete online (Relias) training, training by the Resident Services Director, and shadowing. Additionally, care staff are trained several times per week and as needed.

Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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