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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 10/14/2021
Date Signed: 10/14/2021 11:57:49 AM

Document Has Been Signed on 10/14/2021 11:57 AM - 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: DATE:
10/14/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Penina Tuimaualuga, AdministratorTIME COMPLETED:
12:15 PM
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On 10/14/21 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Bella Villa Elderly Care for the purpose of conducting a required post licensing inspection. LPA met with Administrator, Penina Tuimaualuga and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed bedroom furniture from bedroom on the back lawn and was informed facility discovered bed bugs on 10/13/21. LPA requested incident report. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA conducted file review for staff and residents, LPA did not observe any staff documentation for S2 and S3. In addition, S3's criminal record clearance is pending and LPA observed S3 in the facility assisting residents. LPA reviewed resident files and observed all required documentation for residents. LPA reviewed the medication administration records (MAR) for residents and observed that Resident's R1 and R2 (see confidential names list, LIC 811 dated 10/14/21) both had PM medications that had been marked as administered despite the time and the fact that the medication had not been administered.

LPA measured the water temperature, temperature measured at 112 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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Document Has Been Signed on 10/14/2021 11:57 AM - It Cannot Be Edited


Created By: Kevin Gould On 10/14/2021 at 11:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87465(a)(1)

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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, LPA reviewed medication administration records for all residents and observed errors for R1 and R2 who's
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All staff who administer medications are part of their duties, are required to received medication administrator training from a qualified trainer or organization. The department is requiring the training to come from outside this organization.
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medication logs indicated they had been given pm medications on 10/14/21 despite the time of day, 9:30am and statements from S2 that the medications had not been administered yet which poses an immediate health, safety and personal rights risk for residents in care.
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Type A
10/15/2021
Section Cited
CCR87355(e)(2)

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met evidenced
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Administrator will review criminal record requirements for staff and provide the department with a signed statement that the Administrator understands the requirements and will not have any individuals present in the facility until they have obtained criminal record clearance from the department.
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by, S3 did not have a criminal record clearance prior to being in the facility and working with residents which poses an immediate heath, safety and personal rights risk to residents in care.
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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
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2021 11:57 AM - It Cannot Be Edited


Created By: Kevin Gould On 10/14/2021 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87412(a)(1-13)

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Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(1)Employee's full name.(2) Social Security number.(3) Date of employment. (4) Written verification that
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Administrator will ensure that all employee files are complete with all required documentation in order to meet the regulations. LPA will also recommend facility to TSP for assistance with remaining in compliance with CCLD Regulations. Administrator will submit in writing that she agrees to work with DSS Technical Support Program.
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the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license. (5) Home address and telephone number.(6) Educational background. (7) Past experience, including types of employment and former employers.
(8) Type of position for which employed.
(9) Termination date if no longer employed by the facility.(10) Reasons for leaving.
(11)A health screening as specified in Section 87411, Personnel Requirements - General. (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.
(13)For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance. This requirement was not met as evidenced by LPA observations of staff files that the facility did not have any of the required documentation for staff in their files. which poses an immediate health, safety and personal rights risk to residents in care
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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
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


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