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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 03/10/2021
Date Signed: 03/10/2021 05:01:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BELLA VILLA ELDERLY CAREFACILITY NUMBER:
342700920
ADMINISTRATOR:TUIMAUALUGA, PENINAFACILITY TYPE:
740
ADDRESS:37 MOSSGLEN CIRTELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 0DATE:
03/10/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee, Penina TuimaualugaTIME COMPLETED:
03:30 PM
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On 3/10/21 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing meeting with Licensee Penina Tuimaualuga via Facetime. LPA Gould and Licensee went over the component 3 orientation.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, Health Related Services and Conditions and Dementia Care.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files. LPA and Licensee discussed provider information notices (PINS) regarding COVID 19 and infection control in an RCFE released by the department in 2020 and 2021.

Exit interview was conducted and a copy of this report will be mailed to the licensee for signature. Once approved, a copy of the license will be set to the Licensee.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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