342700920-7-25-2022-27-AS-KHOS-CGPV3W-20220726160526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700920
Report Date: 07/13/2022
Date Signed: 07/25/2022 01:27:42 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2022 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20220525124720

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: 6	DATE:	07/13/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Salote Lewis		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Neglect/Lack of Supervision: Residents are unsupervised.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Bella Villa Elderly Care on 7/13/22 at 1:00pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with staff and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because all neighbors interviewed corroborated the allegation and provided statements to LPA confirming that all interviewed had observed residents unsupervised outside and in front of the home or in the neighborhood unsupervised by any staff members. LPA reviewed all resident files and confirmed that all resident physician assessments indicate that all residents cannot leave the facility unassisted due to a mental or physical diagnosis. Interviews with available staff members were inconclusive and denied knowledge of any residents in the community unsupervised by staff members.

Report continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220525124720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/13/2022

NARRATIVE

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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220525124720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2022 Section Cited CCR 87705(k)(6)	1 2 3 4 5 6 7	Care of Persons with Dementia: Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met as evidenced by statements obtained from all neighbors interviewed where they observed residents outside the facility in the	1 2 3 4 5 6 7	Facility agrees to conduct training regarding care for person's with dementia and ensure all staff members are aware of requirements for supervision for all residents when attempting to AWOL or expressing a desire to exit the facility. Training documentation will be provided by the POC due date.
	8 9 10 11 12 13 14	neighborhood unspurvised by facility staff members. Review of all resident files and physician reports also state no resident may leave the facility unassisted which poses an immediate health, saftey or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 07/22/2022 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse	1 2 3 4 5 6 7	facility has agreed to conduct training for all staff regarding reporting requirements and training on how to fill out an incident report and submit to the department. Documentation of training will be provided to the department by the POC due date.
	8 9 10 11 12 13 14	of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by corroborated reports of resident elopement from the facility unsupervised by staff members and no incident reports received by the department alerting the department of the resident elopements which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC9099 (FAS) - (06/04)

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