342700920-10-21-2022-27-AS-KGOD-CKEL7P-20221021083036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 09/28/2022
Date Signed: 10/21/2022 08:30:45 AM

Document Has Been Signed on 10/21/2022 08:30 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 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:	09/28/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Penina Tuimaualuga, Mark Labella and Jake Reinhart		TIME COMPLETED:	11:45 AM

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	A Non-Compliance Conference (NCC) was conducted today via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting is to discuss the high volume of deficiencies cited/inability to remain in substantial compliance with the regulations/or specific incident that has occurred in the last 16 months. A previous NCC was conducted on 6/14/22. Present in the meeting is Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analysts (LPAs) Kevin Gould and Avelina Martinez, Representatives of Bella Villa Elderly Care LLC: Penina Tuimaualuga, Mark Labella and Jake Reinhart. The Non-Compliance Conference process was explained during this meeting. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensees. Bella Villa Elderly Care has been cited for 17 type A and 6 type B violations of Title 22 as well as civil penalties beginning 4/13/21 to present. The Department has issued citations and civil penalties in the areas of: Resident Records, Criminal Record Clearance, Incidental Medical and Dental Care, Personnel Requirements, Personnel Records, Personal Accommodations and Services, Training requirements for direct care staff, Reporting Requirements and Maintenance and Operation.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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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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: 09/28/2022

NARRATIVE

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The facility has stated on 6/14/22 they will do the following to achieve continued and substantial compliance:

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
All staff cross trained in medication administration and all required training to be complete for all staff. - not 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
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
All staff will be cross trained on reporting requirements and how to document an incident report.
Facility will incorporate a weekly checklist for physical plant and assign staff responsibilities to ensure staff and facility remain in compliance. - met

Issues discussed during the meeting were:

Repeat violations and civil penalties.
Violations: 17 Type A citations and 6 Type B.
Review of Licensee's Plan to become in compliance
Medication Training/errors and consultant feedback implementation
Staffing/Culture
Reporting requirements
Qualified Administrator
Hospice regulations

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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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: 09/28/2022

NARRATIVE

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The facility has stated they will do the following to achieve continued and substantial compliance:

Facility will continue to submit weekly audits of Medication Administration Logs
Facility will submit new documentation to appoint at new administrator and provide LIC 500 with dates/times the administrator will be at the facility.
Facility will submit Hospice Exception request for second resident who has begun hospice services.
Facility will submit documentation of training.
Facility will continue to notify department regarding any future sale of the property or transition to new ownership.
Facility will submit attestation that all resident files are complete with all required records by 10/7/22.

CCLD will do the following:

Increase monitoring and quarterly inspections
Review reports weekly for compliance

The facility was advised that completing a Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. At this time, the Department will re-evaluate compliance in 6 months before referring this case to Legal for Administrative Action.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.

An exit interview was conducted with Penina Tuimaualuga via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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