315003016-8-1-2024-59-AS-MSEY-D7QTJ7-20240801144551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315003016
Report Date: 08/01/2024
Date Signed: 08/01/2024 10:11:31 AM

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
07/22/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240722164103

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: 16	DATE:	08/01/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ilona Corpus		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff failed to seek medical attention in a timely manner
Facility staff failed to assist resident in distress.
Facility staff interfering with hospice agency agent

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday August 1, 2024 to complete and deliver findings to a complaint received on 7/23/2024. 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 R1’s file including face sheet, physicians report, and care plan. The result of the investigation is as follows:

LPA interviewed the Administrator who stated that they worked on NOC shift on Friday July 19th. She performed frequent rounds and had no instances of R1 falling or being on the floor. LPA interviewed all morning staff who worked on Saturday July 20th who stated that when they started their shift, R1 was in bed. Interviews acknowledged that around breakfast time, R1 began to exhibit behaviors and threw their food on the floor. R1 then lowered themselves to the ground. Staff attempted multiple times to assist R1 back into bed, but they refused. R1 was also refusing their morning medications.
Continued on 9099-C

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: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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-20240722164103

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: 08/01/2024

NARRATIVE

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At this point, the Health Services Director called hospice for assistance. Staff interviewed stated that R1 did not state that they were in pain and that they had exhibited this behavior before. Hospice arrived to evaluate and assist resident. Hospice wanted staff to force resident back in bed, even though resident wasn’t wanting staff assistance. 911 was called for a lift assist. Hospice, along with the first responders, assisted R1 back into bed. The hospice nurse then left to attend to another resident at a different facility. A short time later, R1 was given their morning medications.

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: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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