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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:49:08 AM


Document Has Been Signed on 11/21/2022 10:49 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:SALOTE LEWISFACILITY TYPE:
740
ADDRESS:37 MOSSGLEN CIRTELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 5DATE:
11/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Salote LewisTIME COMPLETED:
11:30 AM
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On 11/21/22 at 9:20am, Licensing Program Analyst (LPA) Kevin Gould conducted a Case Management inspection as a quarterly health and safety inspection to ensure the facility is in compliance with title 22 regulations and are providing appropriate care and supervision to resident's in care. LPA met with current Administrator Salote Lewis who was present when LPA arrived at the facility. Current census is 5 residents.

LPA conducted a walk through of the facility and observed all residents to be clean and well groomed. All residents LPA spoke with expressed they had a good breakfast and had all had their coffee this morning. LPA observed several residents request more coffee and were quickly provided with an additional cup. There are currently two staff members present during today's inspection. all staff members are fingerprint cleared and associate to the facility. LPA observed a current administrator certificate displayed for Mrs. Lewis with an expiration date of 8/8/2024.

LPA observed the facility to be clean, sanitary and with no malodorous odor. LPA observed a soft spot on the facility entrance ramp where the wood has rotted away. LPA was informed by administrator that a work order has been scheduled for this Friday, 11/25/22 and would provide LPA with photos of repaired ramp by Monday 11/28/22. LPA reviewed all resident and staff files and observed all files to be up to date. LPA observed two (2) residents did not have a current physician's report and facility was able to provide LPA with documentation of canceled medical appointments by the physician's office and scheduled follow up appointments to have the documents updated. All staff files were complete and LPA observed documented training for all staff members for dementia training to meet residents needs.

Facility is current and in compliance with their acceptance and retention limitations. The facility has a current hospice waiver for one (1) resident and has one (1) current hospice resident.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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 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: 11/21/2022
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Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was 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: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2