Inspection Reports for
Grand River Villa
509 Michigan Blvd, West Sacramento, CA 95691, CA, 95691
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Inspection Report — Oct 15, 2025
Date: Oct 15, 2025
Visit Reason
The visit was a case management inspection conducted due to an incident report involving a resident who eloped from the facility on 10/03/2025.
Findings
The inspection found a deficiency related to failure in care and supervision, as a resident with dementia eloped without staff knowledge, posing an immediate risk to resident safety. Corrective actions including staff training, gate repair, and consideration of a wander-guard system were planned.
Citations (1)
Failure to provide adequate care and supervision resulting in a resident eloping from the facility without staff knowledge.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luceli Soto-Luis | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the case management visit |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report — Jul 14, 2025
Annual Inspection
Date: Jul 14, 2025
Visit Reason
The visit occurred as an unannounced annual inspection to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be clean, well organized, and in compliance with regulations including kitchen safety, resident room conditions, water temperature, medication storage, and fire safety. No deficiencies were cited during the inspection.
Report Facts
Residents present: 25
Caregivers present: 2
Med tech present: 1
Fire extinguisher last charged: Nov 23, 2024
Last fire drill date: Apr 15, 2025
Last fire inspection date: Jun 9, 2025
Water temperature range: 115.3-116.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magda Luis | Administrator | Met with during inspection and discussed First Aid/CPR training |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection visit |
| Maria Ortiz | Resident Care Coordinator | Greeted the Licensing Program Analyst upon arrival |
Inspection Report — Nov 14, 2024
Follow-Up
Date: Nov 14, 2024
Visit Reason
The visit was conducted to follow up on the plan of correction for a previous deficiency and to perform a health and safety check.
Findings
The facility's kitchen was inspected and found to have an ample supply of perishable and non-perishable foods as required. The plan of correction for the deficiency cited on 11/05/2024 has been met, and no new deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Ortiz | Resident Care Coordinator | Met during inspection and participated in exit interview. |
| Robert Godfrey | Administrator | Facility Administrator, participated via phone during inspection. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection visit. |
Inspection Report — Nov 5, 2024
Original Licensing
Date: Nov 5, 2024
Visit Reason
The inspection was an unannounced Post-Licensing visit conducted to evaluate Grand River Villa's compliance with licensing requirements.
Findings
The facility was generally well-maintained with adequate safety measures, but was found deficient in maintaining an adequate supply of perishable and non-perishable foods as required by regulation.
Citations (1)
Failure to maintain supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days as required.
Report Facts
Residents present: 29
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the Post-Licensing inspection and cited deficiencies |
| Maria Ortiz | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
Inspection Report — Jul 29, 2024
Original Licensing
Date: Jul 29, 2024
Visit Reason
The inspection was an unannounced pre-licensing visit to evaluate Grand River Villa for initial licensing as a Resident Care Facility for the Elderly.
Findings
The facility met all requirements under Title 22, California Code of Regulations, with no deficiencies cited. The environment was clean, safe, and well-equipped, and required postings were observed. Resident and employee files were complete.
Report Facts
Residents present: 27
Rooms: 23
Fire extinguisher last inspection date: Oct 18, 2023
Water temperature range: 112-116
Resident files reviewed: 3
Employee files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Paz | Administrator | Met via phone during inspection and mentioned in relation to facility operations |
| Jill Nakagawa | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing the report |
Inspection Report — Jul 15, 2024
Original Licensing
Date: Jul 15, 2024
Visit Reason
The visit was conducted as a pre-licensing readiness evaluation and COMP II interview to verify the applicant/administrator's understanding of community care facility licensing laws and readiness for licensing.
Findings
The applicant/administrator demonstrated understanding of licensing laws, facility operation, medication storage, fire drills, transportation, and filling vacancies. Identification was verified and required documentation was obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Paz | Administrator | Applicant/administrator participating in COMP II interview and verification |
| Mark Cimino | Member | Participant in COMP II interview |
| Julia Kim | Licensing Program Manager | Named in report header and signature section |
| Dianne Ramos | Licensing Program Analyst | Named in report header and signature section |
Report — August 7, 2026
August 7, 2026
Report — July 29, 2026
July 29, 2026
Report — April 24, 2026
April 24, 2026
Report — April 24, 2026
April 24, 2026
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