342700920-4-12-2021-27-AS-KGOD-BZZLHR-20210412084644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 03/10/2021
Date Signed: 04/12/2021 08:46:57 AM

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 CARE		FACILITY NUMBER:	342700920
ADMINISTRATOR:	TUIMAUALUGA, PENINA		FACILITY TYPE:	740
ADDRESS:	37 MOSSGLEN CIR		TELEPHONE:	(424) 345-0820
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95826
CAPACITY:	6	CENSUS: 0	DATE:	03/10/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee, Penina Tuimaualuga		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/10/21 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould conducted a tele-prelicensing inspection for Bella Villa Elderly Care (RCFE). LPA Gould met with Licensee Penina Tuimaualuga and together conducted the inspection. The Licensee is requesting a capacity of six (6) LPA observed the approved fire clearance is for six (6) residents, up to six (6) may be non-ambulatory. Licensee has already request and received approval for one (1) hospice resident. The home is located in a residential area with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry (garage), and backyard. Kitchen water temperature recorded 110 degrees. Bedroom #1: Vacant, to be occupied by two (2) residents. LPA observed two twin beds, adequate storage and lighting and a privacy room divider. Smoke detector is working and operational. Bedroom #2: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #3: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #4: Vacant, to be occupied by two (2) residents. LPA observed two twin beds, adequate storage and lighting and a privacy room divider. Smoke detector is working and operational. This bedroom is equipped with a bathroom. Bathroom #1: is a full bathroom equipped with toilet, shower and sink with appropriate grab bars. Bathroom #2: is a full bath with toilet, sink and shower with appropriate grab bars located in bedroom #4.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700920
	VISIT DATE: 03/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed adequate seating for residents in the kitchen and an appropriate number of plates, cups and silverware to meet the residents needs. Licensee has an appropriate supply of non-perishable food supply and a 2 day supply of fresh perishable foods. LPA observed the medication storage closet in hallway locked in accordance with Title 22 regulations. LPA also observed sharp knives and cleaning supplies locked below the sink. The facility has two working fire extinguishers and fully stocked first aid kit. The back and front yard have appropriate ramps for residents to safely exit the facility. LPA observed appropriate seating in the back yard with shade.

Facility will not transport residents in a facility vehicle or personal vehicle.

An exit interview was conducted with the licensee and a copy of this report was mailed to the facility for signature. Pre-Licensing is complete and this facility has no deficiencies.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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

LIC809 (FAS) - (06/04)

Page: 2 of 2