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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700925
Report Date: 05/27/2026
Date Signed: 05/27/2026 11:28:35 AM

Document Has Been Signed on 05/27/2026 11:28 AM - 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:VILLA NATOMAS ELDERLY CARE LLCFACILITY NUMBER:
342700925
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, BARBARAFACILITY TYPE:
740
ADDRESS:540 ALCANTAR CIRTELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY: 6CENSUS: 6DATE:
05/27/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Walesi VakararawaTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analysts (LPA) Hiratsuka and Mknelly arrived unannounced at the facility to conduct a quarterly on-site visit regarding the Stipulation and Waiver and Order, effective three years from February 6, 2025 to February 6, 2028. LPAs met with staff and explained the purpose of the visit.

During today's visit, LPA conducted a file review to confirm all staff listed on LIC 500 has an active first aid and CPR certificate. LPAs observed training for February through March 2026. Staff member stated there are some files online.

LPAs conducted a physical plant tour.

The following was observed during today's visit:
-the smoke detector was missing from room one. The bracket that holds it was on the ceiling but with no smoke detector. An immediate $500.00 civil penalty was observed during today's visit. *** smoke detector was installed during today's visit***
-One staff training log is not present at the facility. The staff member started end of April 2026. Staff member stated they did not have the required training prior to working by themselves. The staff member does not proof of medication training. Staff stated there is an online training this week.
NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Kerry Hiratsuka
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VILLA NATOMAS ELDERLY CARE LLC
FACILITY NUMBER: 342700925
VISIT DATE: 05/27/2026
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A record review confirmed no residents in care under the age of 60.

Based on the Stipulation and Waiver and Order, Administrator is to be on site 40 hours weekly. LPA is requesting for facility to keep a live time sheet for Administrator in Probation binder.

Reminder, failure to comply with the Stipulation and Waiver and Order may affect facility's licensure.

Based on the above noted deficiencies, the facility will be issued citations pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809-D. Immediate civil penalties of $500.00 was issued today for the smoke detector missing in room 1.

An exit interview was conducted and a copy of this report was left with facility staff.

NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Kerry Hiratsuka
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2026 11:28 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 05/27/2026 at 10:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA NATOMAS ELDERLY CARE LLC
FACILITY NUMBER: 342700925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2026
Section Cited
CCR
87203

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement not met as evidence by the facility based on observation that the smoke detector for room one was not on the ceiling.
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By 05/28/2026, licensee shall submit a statement stating how they shall ensure all smoke detectors are working at all times.
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The bracket that holds the detector was there, but the smoke detector was not, which poses an immedate health and safety risk to resident in care.
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$500.00 immediate civil penalty was issued today due to the smoke detector not on the ceiling of room 1.

***it was installed during today's visit***

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2026 11:28 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 05/27/2026 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA NATOMAS ELDERLY CARE LLC
FACILITY NUMBER: 342700925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2026
Section Cited
HSC
1569.69(a)(2)

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(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
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By 06/05/2026. the licensee shall ensure all staff shall have medication training per the health and safety code and shall submit a written plan of correction how they shall ensure staff have the required training.
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Based on record review, the licensee did not comply with the section cited above in one out of one staff person does not have the required training per the regulations. The training shall be specific to this facility, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2026 11:28 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 05/27/2026 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA NATOMAS ELDERLY CARE LLC
FACILITY NUMBER: 342700925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2026
Section Cited
HSC
1569.625(b)(1)

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(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
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Licensee shall submit a written plan of correction how they shall have staff training for this facility prior to a staff member working at this facility.
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Based on record review and interview, the licensee did not comply with the section cited above inone out of one staff member does not have the required training for this facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Kerry Hiratsuka
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
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