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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701553
Report Date: 12/19/2025
Date Signed: 12/19/2025 01:32:10 PM

Substantiated


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
10/31/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251031145823
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:
12/19/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Facility Staff: Kimberly JoaquinTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not safeguard resident's medication.
INVESTIGATION FINDINGS:
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On 12/19/2025 at 9:15 AM Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff 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. A brief interview with conducted with facilty staff Kimberly Joaquin .

Allegation: Staff did not safeguard residents medication
It was alleged that staff did not safeguard residents medication. This investigation consisted of interview with facility staff, residents, and resident’s (R1) responsible party. On 11/05/2025 LPA Hughes conducted a visit to the facility and spoke with 2 out of 3 facility staff who stated that they were aware of a residents medication missing in the facility, Staff reported that the medication cart is often left unlocked and that staff take breaks in the same room where medications are stored. Interview with 3 out of 3 residents expressed no concerns about their medications not being properly safeguarded. Additional interview with resident (R1) responsible party stated that facility staff (S1) was aware of an incident in which resident medications were not adequately safeguarded.
Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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 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
10/31/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251031145823

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:
12/19/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Facility Staff: Kimberly JoaquinTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Facility smells malodorous.
Staff did not follow proper eviction procedures.
INVESTIGATION FINDINGS:
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On 12/19/2025 at 9:15 AM Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff 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. A brief interview with conducted with facilty staff Kimberly Joaquin .

Allegation: Facility smells malodorous
It was alleged that the facility smells malodorous. This investigation consisted of interviews with facility staff, residents, and facility observation. On 10/31/2025 LPA Hughes conducted interviews with 2 out of 3 facility staff who stated that the facility bathrooms are often unsanitary. Interview with 3 out of 4 residents in care expressed no concerns about the facility being unsanitary, however interview with resident (R1) reported concerns about the facility bathrooms being left unsanitary. LPA conducted a tour of the facility on 10/28/2025 and observed the facility bathrooms to be unclean and left in unsanitary conditions. The allegation was observed not in compliance with Title 22 regulation 87303(a)(1) Maintenance and Operation. As the facility did not ensure the facility was clean, sanitary, and odorless at all times. On 12/19/2025 the facility was cited for complaint control nbr: 27-AS-20251103135013. This citation will not be reissued due to the citation being previously cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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-20251031145823
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: 12/19/2025
NARRATIVE
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Allegation: Staff did not follow proper eviction procedures

It was alleged that staff did not follow proper eviction procedures. This investigation consisted of interviews with facility staff, and resident (R1) responsible party. On 12/19/2025 LPA spoke with the facility licensee who stated that resident (R1) was not evicted from the facility and left the facility because their health care needs were greater than the level of care offered by the facility. Interview with resident (R1) responsible party reflected that the R1 health care needs exceeded the services the facility could provide, and the decision to move the resident was made in the residents best interest after determining that the resident required a higher level of care. Furthermore, R1’s responsible party stated that the facility did not evict the resident from the facility. This allegation could not be corroborated due to lack of information and evidence 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.

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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20251031145823
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: 12/19/2025
NARRATIVE
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This was observed not in compliance with Title 22 regulation 87465(h)(2) Incidental Medical and Dental Care. As the facility did not ensure that residents medication were safely stored and safeguarded, which resulted in medications being missing from the facility.

As a result, this allegation is 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. An exit interview was conducted with Kimberly and Joseline and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20251031145823
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: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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The licensee will ensure that the facility is in compliance with Title 22 regulation 87465(h)(2) at all times. Licensee has implemented changes to medication accessibility including daily med quantity counts, and multiple staff MAR sign off for certain narcotics. Additonally, licensee has provided a medication cart.
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This requirement was not met as evidenced by:
The facility did not ensure that centrally stored medications were kept locked and inacessible in the facility, which resulted in resident (R1) medications missing in the facility.
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 Licensee agrees to conduct professional vendor training for all facility staff on RCFE medication administration. Licensee agrees to submit the who they will contract with for training by 12/22/2025. Additionally, Licensee will submit proof of training by 12/31/2025.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5