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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315003016
Report Date: 08/06/2025
Date Signed: 08/06/2025 01:48:55 PM

Unfounded


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
06/23/2025 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20250623154126
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:35CENSUS: 28DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christina Brown, Resident Care CoordinatorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in a resident's death
Staff did not ensure a resident was properly fed while in care
Staff did not report incidents involving a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Christina Brown to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20250623154126
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: 08/06/2025
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
26
27
28
29
30
31
32
Staff neglect resulted in a resident's death

Records reviewed indicate that Resident R1’s death was not due to facility neglect. Medical records reviewed do not indicate there was staff neglect for R1. The Death certificate does not indicate that R1’s death was questionable in any manner. Therefore, the allegation staff neglect results in a resident’s death is unfounded.

Staff did not ensure a resident was properly fed while in care

Records reviewed indicated that R1 was eating meals appropriately. Interviews conducted with staff indicated that R1 was eating meals and did not refuse meals while in care. Staff encouraged R1 to eat and drink on a daily basis. Therefore, the allegation that staff did not ensure a resident was properly fed while in care is unfounded.

Staff did not report incidents involving a resident

Records reviewed indicate that staff were contacting R1’s responsible party (RP) when an incident occurred. Internal incident reports documented contact with R1’s RP indicating that when an incident occurred staff was contacting R1’s RP to report the incident and update on R1’s status. Therefore, the allegation staff did not report incidents involving a resident is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2