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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701553
Report Date: 07/01/2026
Date Signed: 07/01/2026 05:02:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/01/2026 05:02 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LAKEWOOD VILLA CARE CENTERFACILITY NUMBER:
342701553
ADMINISTRATOR/
DIRECTOR:		SINGH, ANGELINEFACILITY TYPE:
740
ADDRESS:8708 GERBER ROADTELEPHONE:
(916) 682-2867
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 18CENSUS: 13DATE:
07/01/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Charlotte LewisTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On July 1, 2026, Licensing Program Analyst Arvin Villanueva (LPA) arrived at this facility unannounced to conduct the annual continuation visit that was initiated on April 22, 2026. LPA met with designated administrator Charlotte Lewis (AD) and stated the purpose of this visit. This visit was conducted concurrently with a complaint investigation visit.

Record Reviews: During this visit, LPA conducted record reviews. Review of 3 of 13 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Per review, one of the residents (R1) did not have their care plan (LIC625) available for review. Per interview with AD, she stated she did it but cannot find the document. Per review, same resident (R1) has a restricted health condition (C1) but facility does not have a restricted health condition care plan available for review during this visit. Per interview with AD, she stated that she does not know it is needed.
LPA informed AD that LPA will conduct medication review on next visit.

Review of 5 staff files included but not limited to background clearance, first aid/CPR certification, and training. Per review of Guardian, all staff listed on the Personnel Record (LIC500) were associated with this facility.

Facility conducts quarterly Fire/Emergency Drill. Advisory provided to facility to review their Emergency Disaster Plan and Infection Control Plan at least annually and document each review.

Interviews: 3 staff members and 2 residents in care.

Documents Requested: LPA requested a copy of updated Liability Insurance, LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 deficiencies were cited.

Plan of correction and appeal rights were discussed during exit interview with AD. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2026
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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Document Has Been Signed on 07/01/2026 05:02 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/01/2026 at 04:35 PM
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: LAKEWOOD VILLA CARE CENTER
FACILITY NUMBER: 342701553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2026
Section Cited
CCR
87506(d)

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All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
This requirement is not met as evidenced by:
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Per discussion, designated administrator agreed to obtain a restricted health care plan for all residents in care with restricted health condition. Submit documents by POC due date.
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Based on record review and interview, the facility does not have a restricted health care plan for at least one of the residents with restricted health condition who is receiving home health services. This poses a potential health, safety and 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2026


LIC809 (FAS) - (06/04)
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