<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:10:30 PM


Document Has Been Signed on 09/15/2022 04:10 PM - It Cannot Be Edited

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: 6DATE:
09/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Salote LewisTIME COMPLETED:
04:30 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 9/15/22 at 9:10am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to ensure the facility is remaining in substantial compliance with regulations following a non-compliance conference dated 6/14/22. LPA was greeted by staff who allowed access to the facility.

LPA evaluated the following items the facility agreed to complete as part of the ongoing compliance agreement dated 6/14/22:
  • Daily Medication monitoring and audits for residents and document medication refusals. verification will be submitted to the department beginning 6/28/22 and first of the month beginning 8/1/22. - NOT MET. LPA only received 1 medication audit procedure and observed medication documentation errors from 9/1/22 to 9/12/22, 9/13/22, 9/14/22 for one resident. LPA has not received any medication audit report from the facility on 8/1 or 9/1.
  • All staff cross trained in medication administration and all required training to be complete for all staff. - MET
  • Facility will ensure criminal record clearance is associated timely and prior to the employee working with any residents. Staff will be cross trained to ensure compliance and all staff are criminal record cleared and associated to the facility. - MET
  • Facility will incorporate resident file and personnel file checklists to ensure all files are complete. NOT MET. LPA observed one resident with dementia has not had a medical reassessment since 5/25/21. next medical appointment is scheduled for 10/7/22.
  • Administrator will be on site at the facility for a minimum of 40 hours per week for the next 6 months and facility will submit a new LIC 500 to demonstrate the new times the Administrator will be at the facility. -NOT MET. based on statements and observations by LPA, The administrators current Administrator's certificate expired on 8/17/22 and no record of documented training submitted for recertification. in addition, the Administrator has not been at the facility during the times identified on the LIC 500 submitted on 6/28/22.
Report Continued on LIC 9099-C.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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 6


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: 09/15/2022
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
  • All staff will be cross trained on reporting requirements and how to document an incident report. - NOT MET. Facility staff were unable to produce documentation of reporting requirements training.
  • Facility will incorporate a weekly checklist for physical plant and assign staff responsibilities to ensure staff and facility remain in compliance. MET.


LPA also observed that the facility had exceeded the acceptance and retention limits in relation to hospice residents. LPA observed there are two current residents receiving hospice services and the facility only has a hospice waiver for 1 resident. Additionally, LPA was not notified of the second resident receiving hospice services.
Per California Code of Regulations, Title 22 the following deficiencies and civil penalties were issued during today's inspection. See LIC 809D and LIC 421.

An exit interview was conducted with staff and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/15/2022 04:10 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited

1
2
3
4
5
6
7
 Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPAs review of resident medication records which revealed errors in documentation from 9/1/22 to 9/12/22,
8
9
10
11
12
13
14
9/13/22, 9/14/22 for one resident which poses an immediate health, safety and personal rights to residents in care.
8
9
10
11
12
13
14
Type A
09/16/2022
Section Cited

1
2
3
4
5
6
7
Training requirements for direct care staff: All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently
8
9
10
11
12
13
14
with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement was not met as evidenced by facility staff stating to LPA that dementia care training consisted of an 11 minute video and no documentation of training for two of two staff members present which poses an immediate health safety and personal rights risk for 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 09/15/2022 04:10 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by
8
9
10
11
12
13
14
 LPAs review of resident records where LPA observed 1 of 6 residents with dementia has not been medically reassessed since 5/25/21 as evidenced by the 602 dated 5/25/21 which poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
09/16/2022
Section Cited

1
2
3
4
5
6
7
Acceptance and Retention Limitations: Persons who have been diagnosed as terminally ill and who have obtained the services of hospice, certified in accordance with federal medicare conditions of participation and licensure, provided the licensee has obtained a facility hospice care waiver in accordance with the
8
9
10
11
12
13
14
provisions of Section 87632, Hospice Care Waiver, and hospice care is being provided in accordance with the provisions of Section 87633, Hospice Care for Terminally Ill Residents. This requirement is not met as evidenced by, the facility is currently retaining two residents on hospice and the facility only has a hospice waiver for 1 resident which poses an immediate 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/15/2022 04:10 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited

1
2
3
4
5
6
7
Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to
8
9
10
11
12
13
14
permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was nbot met as evidenced by LPAs observations that the Facility Administrator's certificate expired on 8/17/22 and no record of recertification submitted to the department prior to expiration.
8
9
10
11
12
13
14
Type A
09/16/2022
Section Cited

1
2
3
4
5
6
7
Hospice Care Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of
8
9
10
11
12
13
14
admission to the facility and the name and address of the hospice. This requirement was not met as evidenced by LPA being informed that a resident started hospice services on 7/2/22 and had not been notified by the administrator that a resident has begun hospice services within 5 days as required which poses an immediate 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/15/2022 04:10 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited

1
2
3
4
5
6
7
Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by the facility's inability to conform to the applicable laws, rules and regulations as evidenced by several repeat deficiencies including but not limited to staff training for caring for residents
8
9
10
11
12
13
14
with dementia and continued medication documentation errors cited on 4/13/21, 10/15/21, 3/9/22, 5/27/22 and 9/15/22 which poses an immedaite heath seafety and personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6