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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701553
Report Date: 06/24/2026
Date Signed: 06/24/2026 10:15:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
01/08/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260108120509
FACILITY NAME:LAKEWOOD VILLA CARE CENTERFACILITY NUMBER:
342701553
ADMINISTRATOR:SINGH, ANGELINEFACILITY TYPE:
740
ADDRESS:8708 GERBER ROADTELEPHONE:
(916) 682-2867
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:18CENSUS: 15DATE:
06/24/2026
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Facility Staff: Charlotte LewisTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Questionable death.
Staff did not address resident's change in condition.
INVESTIGATION FINDINGS:
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On 06/24/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with Charlotte Lewis and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 15.

Allegation: Questionable death.
It was alleged that a resident in care had a questionable death. This investigation consisted of records review. On 01/09/2026 LPA Hughes conducted a visit to the facility and obtained records pertaining to resident (R1). On 01/14/2026 additional medical records for resident (R1) were obtained from UC Davis Medical Center were reviewed. The records did not identify any circumstances indicating the resident’s death was questionable. Documentation reviewed reflected that resident (R1) had significant medical conditions and began receiving end-of-life care services on 12/30/2025, prior to death. Based on the information obtained during the investigation, there was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated.
Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
01/08/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260108120509

FACILITY NAME:LAKEWOOD VILLA CARE CENTERFACILITY NUMBER:
342701553
ADMINISTRATOR:SINGH, ANGELINEFACILITY TYPE:
740
ADDRESS:8708 GERBER ROADTELEPHONE:
(916) 682-2867
CITY:SACRAMENTOSTATE:CAZIP CODE:
95828
CAPACITY:18CENSUS: 15DATE:
06/24/2026
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Facility Staff: Charlotte LewisTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of care supervision resulted in hospitalization.
Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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On 06/24/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with and Charlotte Lewis explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 15.

Allegation: Lack of care supervision resulted in hospitalization.
It was alleged that lack of care and supervision resulted in hospitalization. This investigation consisted of interviews with facility staff and records review. On 01/09/2026 LPA Hughes conducted a visit to the facility and obtained records for resident (R1). On 06/12/2026 LPA Hughes conducted a follow-up visit to the facility and interviewed three (3) facility staff who stated resident (R1) were sent to the hospital due to the facilities inability to properly monitor (R1) blood glucose levels. It was further stated that (R1) was unable to perform their own injections, and staff performed hand over hand assistance. Records reviewed indicated that resident (R1) was legally blind, had diabetes and required ongoing monitoring of blood glucose levels.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260108120509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 342701553
VISIT DATE: 06/24/2026
NARRATIVE
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*This LIC9099-C is being amended to disclose that this incident will be under review by the department and a future civil penalty may apply.

Records further indicated that resident (R1) subsequently required a higher level of care and was placed on Hospice services on 12/30/2025. Based on the evidence and information obtained this allegation was observed not in compliance with Title 22 regulation 87628(a). As the facility did not ensure a resident in care was provided with adequate care and supervision to meet the residents care needs.

Allegation: Staff did not administer medication as prescribed.
It was alleged that staff did not administer medication as prescribed. This investigation consisted of interviews with facility staff. On 01/09/2026 LPA Hughes conducted a visit to the facility and obtained records for resident (R1). On 06/12/2026 LPA conducted a follow-up visit to the facility and interviewed two (2) facility staff who stated that resident (R1) medications were not administered as prescribed as the medications were expired. Staff further stating that the facility notified (R1)’s POA, prescribing pharmacy however, the facility was unable to obtain replacement medications prior to their expiration. Records review did not indicate that resident (R1’s) medication had expired. Additionally, the facility did not provide documentation supporting its claim that the medications had expired, nor did the facility provide documentation demonstrating efforts to obtain replacement medications. Based on the information and evidence obtained, this allegation was observed not in compliance with Title 22 regulation 87628(b)(2). As the facility did not ensure sufficient medications were available for the resident’s diabetic care needs.
As a result, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.
This incident is currently under review, and a future civil penalty may apply pursuant to H&S Code section 1569.49(f).

An exit interview was conducted with Charlotte copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260108120509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 342701553
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2026
Section Cited
CCR
87628(a)
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87628 Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing...and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by a skilled professional.
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The facility agrees to remain in compliance with Title 22 regulation 87628 at all time. The facility will review Title 22Restricted Health Conditions and Diabetes with facility staff and send a statement of acknowledgement of the regulation, including a staff sign-in sheet of all staff who attended training.
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This requirement was not met as evidenced by:
Based on interviews with facility staff it was learned that resident (R1) was unable to perform their own glucose testing, monitoring, and injections as they were legally blind, and required ongoing assistance and supervision with diabetes related care.
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Type A
06/26/2026
Section Cited
CCR
87628(b)(2)
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87628 Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following (2) (2) Ensuring that sufficient amounts of medicines...other supplies are maintained and stored in the facility as specified...
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Review resident pre-placement process, and ensure resident medication and supplies are sufficient in the facility. The facility agrees to implement additional screening efforts prior to resident placement inside of the facility.
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This requirement was not met as evidenced by:
Based on staff interviews, resident (R1) prescribed diabetic medications were not administered as ordered. It was stated the medications were expired. As a result, resident (R1) did not receive prescribed diabetic medications.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260108120509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 342701553
VISIT DATE: 06/24/2026
NARRATIVE
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Allegation: Staff did not address residents’ change in condition.

It was alleged that staff did not address residents’ change in condition. This investigation consisted of interviews with facility staff and residents. On 01/09/2026 LPA Hughes conducted a visit to the facility and obtained records for resident (R1). On 06/12/2026 LPA conducted a follow-up visit to the facility and interviewed 3 facility staff who stated that residents are monitored for changes in condition, facility administration is notified when a resident condition worsens, and residents are sent to the hospital when medically necessary. LPA interviewed 5 residents who stated that they have no concerns regarding the facility addressing changes in resident conditions. Based on the information obtained during the investigation, there was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.


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SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5